HomeMy WebLinkAbout0012 GERALDINE ROAD - Health i 12 GERALDINE ROAD
- - - - ---- - - -- ---- � � COTUIT
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AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION /A G C 4 (.-Il cle R V SEWAGE #,_GOO
VILLAGE_ C OT(/ / ASSESSOR'S MAP&LOT0 -rPO
INSTALLER'S NAME&PHONE NO. A C CJ hl JY el t S'0,,(!
SEPTIC TANK CAPACITY D
LEACHING FACILITY: (type)Z-/"L o to C4o'.4W/'deg S (size) j 00
NO.OF BEDROOMS
B @R OWNER C ; �t2 fl,�4 d
PERMITDATE: 1,27" fir—Z��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 o�chi facili Feet
Furnished by 13 ,
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http://issgl2/intranet/propdata/prebui.lt.aspx?mapp '"`()40009&seq=1 12/1/2014
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TOWN OF BARNSTABLE
'LOCATION 4�, G eX AG 6�/.U.e f2 V SEWAGE O,yd 6—
r-
. VILLAGE COT / It ASSESSOR'S MAP & LOT0 ;.PO
INSTALLER'S NAME&PHONE NO. 10, Al A C Ohl di Cif t E-O W,'
SEPTIC TANK CAPACITY D
LEACHING FACILITY: (type)ZaA1-OwC&,4Wf Se-f"S (size) J—OD
NO. OF BEDROOMS
R R OWNER f .
PERMIT DATE: Z-71", '�f 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 41echi facility). Feet
Furnished by
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Commonwealth of Massachusetts
Title 5 Official Inspection Form' s
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
M 12 GERALDINE
Property Address
- a
Owner Owner's Name
information is required for COTUIT MA '-" 12-20-14 `
every page. City/Town State„ _ Zip Code Date of.lnspection
Inspection results must be submitted on this form. Inspection forms may not 1i6altered in any.
way. Please see completeness checklist at the end of the form.`
Important:
When filling out A. General Information
forms on the I
computer,use 1. Inspector: a 0
only the tab key
to move your DOUGLAS A BROWN'
cursor-do not Name of Inspector '•,` ,
use the return
key. D.A.BROWN INC x
d
Company Name ;
P.O. BOX 145
Company Address ✓
CENTERVILLE p A, 02632;
M
'eAOA City/Town r State ' Zip Code
508-400-7159 S14297.,
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,Cime 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: x.
® Passes ❑ �Conditionally;Passes 7 ❑ Fails
❑ Needs Further Evaluation by,the Local Approving Authority, e
12-20=14 -
ectors Signature Date
. ::
The system inspector shall, ubmit 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. -
1
****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.
r /V
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts. .
r_. Title 5 Official Inspection Form
\akSubsurface Sewage_Disposal System,Form Not for Voluntary Assessments'
M 12 GERALDINE
Property Address ,.P ,
Owner Owner's Name
information is
required for COTUIT - MA. 12--20-14 "
every page. CitylTown Y State j Zip Code• Date of Inspection
B. Certification (corit.) .,
Inspection Summary: Check A,B,C,D'o�E Y always complete all of Section D r
A) System Passes:
`' }
+ ® 1 have not found any information which indicates that any of the failure criteria described • ,
in 310 CMR 15'3031or in 310 CMR 15.304,exist.. Any failure criteria not evaluated are,*
indicated below. a . •,
Comments:
HOUSE HAS BEEN VACANT FOR SOME TIME LEACH CHAMBERS WERE DRY WITH NO SIGNS ,
OF FAILURE AT TIME OF INSPECTION. CAN NOT PREDICT FUTURE PERFORMANCE OF
SYSTEM UNDER THE SAME OR INCREASED USE
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 completi on,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.'riot.- .
r
f 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. - f R
*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.,
0 Y . E N 0 ND (Explain below).
,
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts " .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • -
�M 12 GERALDINE
Property Address *'
Owner Owner's Name .. y
information is MA ' ' • 12-20-14
required for COTUIT -..
every page. Cityrrown State Zip Code, Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational:System will pass with,Board of Health approval if .
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):"
❑ Observation!of sewage backup or,break out or high static water level in the distribution box dues
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will- L
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced` y❑ Y' ❑ N ❑ ND (Explain below)
❑' obstruction is removed ❑ Y ❑� N •❑ ^ND`(Explain below): * ._
❑. '.distribution box is leveled or replaced ,;❑ Y ❑, N, ❑ ND(Explain below): r
r . 4,� '
f
❑ The system required pumping more tlian 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 below):
❑
, obstruction is removed " - ��� ❑ �Y ❑ N ❑•ND(Explain below)
r
11 C) Further,Evaluation is Required by the Board of,Health: f
El 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)(4)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 _
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17,._"
Commonwealth of Massachusetts
m Title 5 Official ,Inspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 12 GERALDINE '
Property Address
Owner Owner's Name
information is required for COTUIT ° MA ~ F 12-20-14
-
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply. ,~ a
❑ 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 thanl100 feet but 50 feet or _
more from a private water supply well**: a ,
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, tor„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.
3. Other:
p . .ir'.
D) System Failure Criteria Applicable to All Systems:.,',-,,
s You must indicate"Yes"or"No to each of the following for all inspections:.
Yes' No J. .
Backup of sewage into facility or system component due to overloaded or'`
❑ ® Y clogged SAS or cesspool
• . Discharge or ponding of effluent.td the surface of the ground or surface waters,,,
❑ �. ® due to an overloaded or clogged SAS or cesspool
4-
El
` ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool y
Liquid depth in cesspool is less than 6" below invert or available volume is less
4 ® than '/2 day flow
t5ins•3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.
M y` 12 GERALDINE- -
Property Address -
Owner Owner's Name w
information is required for COTUIT TM MA '" 12-20=14 ~
every page. CitylTown State' ? •Zip Code Date of Inspection
B. Certification (cont.) `
Yes No f .
❑ ® Required pumping more than 4 times in the last year NOT dueto'clogged or F
- 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. . , w
[:1 ® Any portion of a cesspool or'.privy is within a Zone,.1"of a public well.
El ® 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 thari'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 2000gpd-
❑ ® 10,000gpd.
The system fails. I have determined that one or more of the above failure `
E] ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a.- }
design flow of,10,000 gpd to 15,000 gpd.. ;
For large systems, you must indicate either"yes"or"no"to each of the following,'in addition to the
> questions in Section D. -
ti
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 '
El El Area—IWPA)or a mapped Zone II of a public water supply well, p
If you have answered"yes"to any question in Section E the system is considered a significant threat,,
y
or answered"yes" in Section D above the large system has failed. The owner or operator of an 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 '
Commonwealth of Massachusetts _•
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 12 GERALDINE
Property Address
Owner Owners Name
information is COTUIT MA 4: 12-20-14
required for _ "
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist t
Check if the following have been done. You must indicate"yes"or."no"as to each of the following:
Yes -No f ;
❑ ® 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? -
® ElWere 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? y
❑ ® Were all system components, excluding the SAS, located on'site?
0 ❑ 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?
0 ® Was the facility ovVner(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: o ;
® ❑ 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(5)]
D, System Information
Residential Flow Conditions: -
Number of bedrooms(design): 3 2per as-builtNumber of,bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): A 330
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts f
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 12 GERALDINE
Property Address
Owner Owner's Name
information is UIT MA 12-20-14
required for COT -
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description: v
according to as-built system consists of a 1500 gallon tank d-box and 2 500 gallon chambers with
stone
Number of current residents: .` 0
Does residence have a garbage'grinder? ❑ Yes_❑ No .t
Is laundry on a separate sewage system? (Include laundry system inspection: Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? , - El
Yes ❑: No
R
Water meter readings, if available last'2. ears usage d house vacant
Detail:
house vacant
Sump pump? py '❑` YesA❑ No
Last date of occupancy:
r<, Date `
Commercial/Industrial Flow Conditions: °
Type of Establishment: s,
Design flow(based on 310 CMR 15.203); Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.): }
Grease trap present? El
Yes El No' `
,Industrial waste.holding tank presents El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts ', ' •' '
Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 12 GERALDINE
Property Address
Owner Owner's Name
information is
required for COTUIT 'MA., 12-20-14
every page. City/Town, .State Zip Code' Date of Inspection'
D. System Information (cont.)
Last date of occupancy/use:
s Date.t
Other(describe below):
General Information
Pumping Records:
Source of information: �
Was system pumped as part of the inspection? ' _ ❑h Yes ® No •3
If yes,-volume pumped: "
gallons.
How was quantity pumped determined?
Reason for pumping:
Type of System:
® m Septic tank, distribution box, soil absorption system
❑ Single cesspool ' ., " t•.
El Overflow cesspool 1.,
El , ' Privy '�'.
r ❑ 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):
t5ins 3/13
',, • � 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 „
Commonwealth of Massachusetts - k F
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 12 GERALDINE
Property Address ,
Owner Owner's Name ,
information is - w
required for COTUIT MA. 12-20-14
every page. Cityfrown . t State "Zip Code "Date of Inspection
D. System Information,(cont.).
Approximate age of all components, date installed (if known) and source+of information: r
2000 per as-built
Were sewage odors detected when arriving at the site? !❑ Yes ® 'No
Building Sewer(locate on site plan): `
Depth below grade:
-feet
Material of construction: T
El cast iron ❑ 40 PVC s- ❑ other(explain);
Distance from private water supply well or suction line: feet ,♦r:
Comments(on condition of joints, venting, evidence of leakage, etc.): 1
, e° < A., a f. ♦ • . r
i
Septic Tank(locate on site plan):
Depth below grader 1.25
x feet
Material of construction:' q '
® concrete El metal ❑fiberglass r ` ❑:polyethylene El other-(explain) _
If tank is metal, list age:
. years
Is age confirmed by a Certificate of Compliance?(attachfa`copy of certificate) ❑ Yes ❑. No
1500 per as-built
Dimensions: _
y Sludge depth: Y light
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System
F orm Not for VoluntarY Assessments
,
5
12 GERALDINE ,* -
Property Address ,
Owner Owner's Name
information is
required for COTUIT Mk' 1240-14
every page. Cityrrown State• "" Zip Code ' Date of Inspection'
D. System Information (cont.)
Septic Tank(cont:) r ,
Distance from top of sludge to'bottom of•outlettee or baffle
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee'or baffle
How were dimensions determined?' wooden pole
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 looked fine at time of inspection with mostly clear liquids property has been vacant for some
time. ,
Grease Trap(locate on site plan): s
Depth below grade,
feet-
Material of construction:
0 concrete ❑ metal ❑ fiberglass •❑ polyethylene".,- Elothe,r(explain):
Dimensionv. Y
.. Scum thickness
t •.
r e .t
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
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
u
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments: _ , -
�M 12 GERALDINE
Property Address
Owner Owner's Name
information is `
required for COTUIT MA 12-20-14
every page. City/Town
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 aftime of inspection) (locate on site plan):
t
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass 0 polyethylene. 4`❑ other.(explain):
Dimensions:
Capacity: .. r
gallons
Design Flow:
gallons per day f
Alarm present: El Yes ❑ No
E,
Alarm level: Alarm in working order.l El Yes ❑ No -
Date of last pumping:', .
Date ,. ..
Comments (condition of alarm and float switches, etc.):
fn
.17
y` t
Attach copy of current pumping contract(required). Is copy attached? • ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form �: • k
a Subsurface Sewage Disposal System form -Not for Voluntary Assessments
12 GERALDINE `5 i
Property Address
Owner Owner's Name
information is } ''
required for COTUIT MA .12-20-14
every page. City/Town State Zip Code :Date of Inspection
D. System Information
Distribution Box(if present must be opened) (locate on site.plan): ,;• ,' .
0"
Depth of liquid level above outlet invert
4
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)
box level no leakage at time of nspection f
Pump Chamber(locate on site plan):
Pumps in working order. El Yes No'
Alarms in working order:,, Yes` y'No*
Comments(note condition of.pump chamber, condition of pumps and appurtenances, etc.):
"if pumpsA r alarms are not in working order, system is'a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why;
' t5ins•3/13 -
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
12 GERALDINE
Property Address
Owner Owner's Name x
information is required for COTUIT MA . 12-20-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type. R , .
❑ leaching pits number:
leaching chambers - number: :2
❑ r -leaching galleries ` _ number: ,
❑ leaching trenches numberjength: +
❑ 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.):
chambers were opened and found to be dry with no signs of_failure at time of inspection
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth-top of liquid to,inlet invert
•
Depth of solids layer 4
Depth of scum layer '
Dimensions of cesspool
Materials of construction
.41
, ..
`Indication of groundwater inflow ❑ Yes ❑ No
t5ins 3/13 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts �•
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Vol untary'Assessments,:
wM 12 GERALDINE
Property Address r
r-
Owner Owner's Name r
information is COTWIT MA {
required for 12-20-14
every page. CitylTown State J'Zip Code Date of Inspection,
D. System Information (cont.) R
Comments(note condition of soil, signs of hydraulic failure, level of ponding,:conditiori of vegetation,.
etc.):
Privy(locate on site plan): ¢f•
Materials of construction: + <4 F
Dimensions ,
aa• - • ;..y r
Depth of solids
Comments (note condition of soil; signs of hydraulic failure, level of pondirg, condition of vegetation,
etc.):
t5iris•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 12 GERALDINE
Property Address
Owner Owner's Name
information is COTUIT MA. = '12-20-14
required for _
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) r
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 - :r
.. ..
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 12 GERALDINE r
t '
Property Address a
Owner Owner's Name 1
information is required for COTUIT MA .' 12-20-14'
every page. Cityfrown State Zip Code Date of Inspection ,
D. System Information (cont.) ;
Site Exam: r
® Check Slope ' ,
® Surface water,
® Check cellar ,
® Shallow wells'
Estimated depth to high ground water: j s. greater than 5 ft..
• 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:, a Date
® Observed site(abutting property/observation hole within 150 feet of SAS) ;
❑ Checked with local Board of Health-explain:
• x;.
❑ Checked with local excavators, installers-(attach documentation)' -
❑ Accessed USGS database-explain t
You must describe how you established,the high,groundwater elevation: ,
property sits at a high elevation f
I '
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts'
Title 5 Official Inspection Form
• Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments
wM 12 GERALDINE r
Property Address
Owner Owner's Name Y
information is COTUIT MA • ' - '12-20-14
required for
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D;'or E checked,.
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed '
® System Information Estimated depth to high groundwater ' r
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r
` _ •. ^. •€ �.. .. .. - ••k,. •, ; .. • � , .. •. III
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'-"Page 17 of 17
Assessing As-Built Cards ,. ; " Page 1 of 2
} �4
l ` TOWN OF BARNSTABLE
LOCATION 4� G C'X AL 2 // R b SEWAGE#& OO
VILLAGE_C_O r(/ /1 ASSESSOR'S MAP&LOT i:r _p0 , -
INSTALLER'S NAME&PHONE NO.. P. Al A C ri-A a ez t 5, di '
SEPTIC TANK`CAPACrrY /. J-b o ,
LEACHING FACRM:(typ )Zlr404VCf/AN/'SP.0 (size) So0''
NO.OF BEDROOMS ,�J f
IMMOM OR OWNER C��1ri f/�.�iJ l�t.4! "
PERMUDATE: !9"�«o�IWA&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 s
within 300 feet of1whiBLfacil�l, _ r _Fee
Furnished by 4� rl j� PAW
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http://w.ww.townofbamstable.us/Assessing/HMdisplay.asp?mappar=040009&seq=l 12/22/2014 . .
No. 0 _7TY Fee $ 5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
�t PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipplication for MiopoOl *pgtem Cottgtruction Permit
Application for a Permit to Construct( )RepairXX);Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 12 Geraldine Road Owner's Name,Address and Tel.No.
CotuitMss 02635 Jim Perkins
Assessor's Map arcef
Installer's Name,Address,and Tel.No.5 0 8—7 7 5—3 3 3 H Designer's Name,Address and Tel.No.5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc
Box 66 Centerville,Mass, 02632 jBox 66 Centerville,Mass. 02632
Type of Building:
Dwelling XX No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 355 gallons per day. Calculated daily flow?/1 1 0L2 2 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Add i ng t-wo S 0 0 cla 1 1 on 1 ea ch i n g
chambers_ packed in 4 ' of 1;" stone. Presently there'�:are
'two�blocic c G'�nool s ' Thi G wi 1 1 he bmitted
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 this Bo ofjH.2al
Signed Date 1 2/6/0 0
Application Approved by Date
Application Disapproved fo the following reasons
Permit No. Date Issued
W -
� x4 ..`WA
f �iQ- '_71/ Fee $ 50.
r No. Entered in computer: ✓
THE COMMONWE*tTM-OF MASSACHUSETTS
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Ztppfication for Construction Permit
Application for a Permit to Construct( )Repair*X*Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. 12 Geraldine Road Owner's Name,Address and Tel.No.
CotuitMass. 02635 . Jim Perkins
Assessor's Map/Parcel C 16 Q
09
Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc
Box 66 Centerville,Mass, 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XXNo.of Bedrooms 2 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 5 5 gallons per day. Calculated daily flow 2/1 1 0-2 2 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil'
Nature of Repairs or Alterations(Answer when applicable) Adding two 500 gallon leaching
chambers packed in 4 ' of 11" stone. Presentl# there t'e
i*wW OA c c St
jkMAndTjlis will be omitted
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 iss=this Bo WDate
Signed 1 2/6/0 0
Application Approved by r Date
Application Disapproved fo the following reasons
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*XX)Upgraded( )
Abandoned( )by J.P.Macomber & Son Inc. i
at 12 Geraldine Road Cotuit,Mass. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. Wes-7 S Y dated 1 Z- Z l Za 0 .
Installer J.P.Macomber & Son Inc/ . Designer J.P.Macomber & Son Inc.
The issuance of this permit shall not be construed as a guarantee that theye. ill function as designed..-,.-,-,,,.
Date ,' ^«�' ~°' �'� Inspecto �
---------------------------------------
Fee
OfU- � THE COMMONWEALTH OF MASSACHUSETTS
9
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
ItZpog;al 6potem Conotruction Permit '
Permission is hereby granted to Construct( )Repair( jWpgrade( )Abandon( )
Systemlocatedat 12 Geraldine Road Cotuit,Mass.
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must b completed within three years of the date of this permit.
Date: Z Approved by 1.
14
l/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
Joseph P.Macomber Jr-, hereby certify that the application for disposal works
construction permit signed by me dated 12 16/0 0 concerning the
property located at 12 Geraldine Road Cotuit,Mass. meeis all of the
following criteria:
/The failed system is connected to a residential dwelling
only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to S minutes per inch.
:.
There are no wetlands within 100 feet of the proposed septic system
ere are no private wells within 150 fat of the proposed septic system
There is no increase in flow and/or change in use proposed
/There are no variances requested or needed.
V The bottom of the proposed leaching facility will not located less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using'the Frimptor
t/method when applicable]
if the S.A.S. will be located with 250 fat of any vegetated wetlands, the bottom of the proposed
g P Po
leaching facility will M be located less than founcen (14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A) Top of Ground Surface Elevation(using GIS infoimadon)
B) G.W. Elevation '� +the MAX. High G.W. Adjustment leaCa ,
X DMFERENCE BETWEEN A and B
SIGNED : , DATE: li��^103
(Sketch posed plan of system on backJ.
Q:hcaith folds ccn
k
C sL
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V
1
V
r® '`
TOWN OF BARNSTABLE
LOCATION C t?/ AL/�/.f/e SEWAGE #x 000
VILLAGE C 0 n.Z /L ASSESSOR'S MAP & LOT:� "',00
INSTALLER'S NAME&PHONE NOJ /a, A4 A C U A4 { el
SEPTIC TANK CAPACITY
LEACHING FACILITY: l"LoCucHA,t9i4P� s size
- (type - � (size) s'oD
NO. OF BEDROOMS
BR19R OWNER C it - f
PERMITDATE: " /F - COMPLIANCE DATE:/ `' L:•F
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 o chi facili ) Feet
Furnished by 4fC Ij
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Commonwealth of Massachusetts ,
W Title 5 Official Inspection Form ram`
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , `
12 Geraldine Road CLA0- o`\n
Property Address 16
Barbara Stone U1 Go
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
4
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector: 7k � 1;1.
only the tab key `L t ,
to move your Robert Paolini
cursor-do not Name of Inspector
use the return ` "t
key. Capewide Ent'erprises,LLC `=
Company Name
rx`
r� P.O.Box 763
Company Address
Centerville Ma. A632
City/Town State Zip Code
(508)428-4028 S14454
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
3/28/2008
InspecYor'sl§ig aLurvDate
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 sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
12 Geraldine Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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:
The septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes,no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System.will
pass inspection if(with approval of Board of Health):
❑. broken pipe(s)are replaced
❑ obstruction is removed
12 Geraldine Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 31/28/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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:
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
151303(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.
12 Geraldine Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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.
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
El ® 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 %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.
12 Geraldine Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 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 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails..The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner'should contact the appropriate
regional office of the Department.
12 Geraldine Rd.•03/08 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
G
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town 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 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
El 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:
® ❑ 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(5)]
12 Geraldine Rd.-M/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
r
Commonwealth of Massachusetts '
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town State Zip Code - Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): \ 3, Number of bedrooms (actual): 2
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 ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
,000
:42
Water meter readings, if available (last 2 years usage (gpd)): 2002006:4 ,000
Sump pump? ❑ Yes ® No,
Last date of occupancy.: 3/28/2008
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
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):
12 Geraldine Rd.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Last pump 3/13/2006 by Robinson Septic
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)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.
y
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
System installed in 2000
Were sewage odors detected when arriving at the site? _ ❑ Yes ® No
12 Geraldine Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is.
required for Cotuit Ma. . 02635 3/28/2007
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
i
1,
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10`+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
1
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: 1500 Gallon
Sludge depth: 31'
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
1'
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 14"
How were dimensions determined? Measured .
12 Geraldine Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town 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.):
Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
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: 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.):
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):
12 Geraldine Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
cwM 12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town. State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on,site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
12 Geraldine Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
c
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 . 3/28/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 LC
❑ '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.):
Sandy dry soil.No signs of hydraulic failure.6"of water in leaching chambers at time of inspection.No
stain line visible.
12 Geraldine Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of.soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
12 Geraldine Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Map Page I of 2
Town of Barnstable Geographic Information System
Parcel Viewer Custom Map Abutters Map Size ❑ ❑ Zoom out IJ J J J J J In
100
j
�10
0 20 Fee
Set-Scale 1" = 20 . " I Aerial Photos '
(',A hf')flnr._9l1f)7 Tr... of P.r tohlo PAA All rinh+c rroeeni
http;//www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=040009&map... 3/28/2008
I .
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 12 Geraldine Road
Property Address
Barbara Stone
Owner Owner's Name
information is required for Cotuit Ma. 02635 3/28/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® .Surface water
® Check cellar
❑ Shallow wells k
Estimated depth to high ground water: Bottom of LC 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:
As-Built Card
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of
groundwater elevations.
12 Geraldine Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Town of Barnstable
OF THE 1p�
Regulatory Services
BARNSPABM ; Thomas.F. Geiler,Director
v$ MAS& `�g
p,E16 9. 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
not does this Division agree with any technical observation s and interpretations .
contained within this report.
In addition b receiving this report the Town
of Barnstable Y g p � 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.
t
Commonwealth Of Massachusetts
Executive Office Of Environmental Affairs
Department Of Environmental Protection
TITLE 5
Official Inspection Form -Not For Voluntary Assessments
Subsurface Sewage Disposal System Form
Part A
Certification
Property Address: 12 Geraldine Rd.Cotuit Ma.02635
Owners Name:Barbara Stone
Owners Address: 12 Geraldine Rd.Cotuit Ma.02635 �.3
Date of Inspection:3/11/2006
U�o do :
Name of Inspector(please print)Sean M.Jones
Company Name:S.M.Jones Title V Septic Inspectors
Mailing Address: 74 Beldan Ln.
Centerville Ma..02632
Telephone Number:508-7784597
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system:
X Passes
Conditionally Passes "
Needs further evaluation by the Local Approving Authority:
Fails
Inspectors 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 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.
Page I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART A
CERTIFICATION(CONTINUED)
Property Address: 12 Geraldine Rd.Cotuit Ma.02635
Owner: Barbara Stone
Date of Inspection:3/11/2006
W
Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: ^
X 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:N/A'
One or more system components as described in the"Conditional Pass"section need to be replaced or
Repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the-for the following statements. If"not determined"please
Explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
Unsound,exhibits substantial infiltration or exfiltration or the 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 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
NI)explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 12 Geraldine Rd.Cotuit Md:02635
Owner: Barbara Stone
Date of Inspection:3/11/2006
C.Further Evaluation is required by the Board of Health:N/A
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 310CMR 15.303(l)(b)that the
System functioning in a manner that protects the public health,safety and the environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
Surface water supplyor 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 less than 100 feet but 50 feet or more from a
Private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
Bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other,
Failure criteria are triggered.A copy of the analysis must be attached to this form.
3.Other: _ I
M
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 12 Geraldine,Rd.Cotuit Ma.02635
Owner: Barbara Stone
Date of Inspection:3/11/2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or'available volume is less than '/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of cesspool or privy is within Zone 1 of a public well.
X Any portion of cesspool or privy is within 50 feet of a private water supply well.
X Any portion of 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 pp,provided that no other failure criteria ,
are triggered.A copy of the analysis must be attached to this form.]
X (Yes/No)The system fails.I have determined that one or more of the above criteria exist as'
described in 310 CMR 15.303,therefore the system fails.The system owner should'contact the Board'of
Health to determine what will be necessary to correct the failure.
E. Large systems: N/A
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:
Yes No ..
_ the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you 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.
CM 15.304.The system owner should contact the appropriate regional office of the Department.
f
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 12 Geraldine Rd.Cotuit Ma.02635
Owner: Barbara Stone
Date of Inspection:3/11/2006
Check if the following have been done You must indicate"yes"or"no"as to each of the following-
Yes No -
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of system components pumped out in the previous two weeks?
X — Has the system received normal flows in the previous two week period?
_X_ — Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X _ Was the site inspected for signs of break out?
_X _ Were all system components,excluding SAS,'located on site? a
_X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_X_ — Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
X_ _ Existing information.For example,a plan at the Board of Health.
_X_ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance ,
Is unacceptable)[310 CMR 15.302(3)(b)]
p a s'
.. J., .'+�,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
Property Address: 12 Geraldine Rd.Cotuit Ma.02635
Owner: Barbara Stone
Date of Inspection:3/11/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 2-3
DESIGN flow based on 310 CMR 15.203(for example): 110 gpd x#of bedrooms): 330 GPD
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no):_No [if yes separate report required] h
Laundry system inspected(yes or no):—N/A
Seasonal use:(yes or no)No_
Water meter readings,if available(last 2 years usage(gpd):9005. 7(0,0p0 P00Y V,00,
Sump pump(yes or no): No
Last date of occupancy/use: Current
COMMERCIAL/INDUSTRIAL:N/A
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: 2000-New System
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was this quantity pumped determined?
Reason for pumping: -
TYPE OF SYSTEM
_X Septic tank,distribution box,soil absorption system
Single cesspool a "
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 the 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: 2000/As-built
Were sewerage odors•detected wheri arriving at the site(yes or no): No ry
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Geraldine Rd.Cotuit Ma.02635
Owner: Barbara Stone ;
Date of Inspection:3/11/2006
BUILDING SEWER(locate on site plan)
Depth below grade: 2-3` below TOF
Materials of construction:_X_cast iron_X 40 PVC - other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints were in good condition.venting was good..no sign of leakage.
SEPTIC TANK: X_(locate on site plan)
Depth below grade:_6"_
Material of construcrion:_X_concrete metal fiberglass_polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 1500 Gallons
Sludge depth: 18"
Distance from top of sludge to bottom of outlet tee or baffle:_2.5`
Scum thickness:_4"
Distance from top of scum to top of outlet tee or baffle: T&
Distance from bottom of scum to bottom of outlet tee or baffle 12"
How were dimensions determined: Opened covers and took measurements.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
As related to outlet invert,evidence of leakage,etc.):
Septic tank has not been cleaned since it was installed in 2000 Although tank is not real bad it could use a cleaning:"
Inlet and outlet tees were intact and in good condition Tank was structurally sound Tank was not leaking
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass ''_polyethylene :p
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.).
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Geraldine Rd.Cotuit Ma.02635
Owner: Barbara Stone
Date of Inspection:3/11/2006
TIGHT or HOLDING TANK: N/A (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:
Continents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:_X_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0"
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.):
Distribution box was level and in good condition No solids carryover. Box was not leaking
PUMP CHAMBER: N/A (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.): + '
I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Geraldine Rd.Cotuit Ma.02635
Owner: Barbara Stone
Date of Inspection:3/11/2006
SOIL ABSORPTION SYSTEM(SAS):_X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
Leaching pits.Number:
_X_Leaching chambers,number:_2_
Leaching galleries,number:
Leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternitave system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Soil was dry,no sign of hydraulic failure Vegetation was normal At time of inspection leach chambers had 2 P
of available leachmg.
CESSPOOLS: N/A (cesspools must be pumped as part.of inspection)(locate on site plan) .
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
------------
PRIVY: N/A (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.):
1 - $•
I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: :12 Geraldine Rd.Cotuit Ma.02635
Owner: Barbara Stone
Date of Inspection:3/11/2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
}
Estimated depth to ground water 20`+/-Below S.A.S.
Please indicate(check)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:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable Groundwater Contour Map.
7
K ,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `.
SYSTEM INFORMATION(continued)
Property Address: 12 Geraldine Rd.Cotuit Ma.'02635
Owner: Barbara Stone
Date of Inspection:3/11/2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or
Benchmarks.Locate all wells within 100 feet.Locate where water supply enters,the building
:G
REAR OF HOUSE
A
C B ,
1 . TANK
A-1=37'
07 2 " D-BOX
3 A-2=49'
B-2=26'
S.A.S.
B-3=28'
C=3=28'
i
TOWN OF BARNSTABLE �+/y
LOCATION /Z ,(j--trAld rfn2 /?� SEWAGE # v
VILLAGE co�eJ ASSESSOR'S MAP & LOT OqO '00'9
INSTALLER'S NAME & PHONE NO. Fv `i"' ►a 6kf 111d I'm 15 27
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) Ahz e4w6k (size) �olZ=p
0
NO. OF BEDROOMS 3 PRIVATE WELL O PUB�WATER
BUILDER OR OWNER t e, j^1 z S �Zr A i�S
DATE PERMIT ISSUED: I O UJ*j?Q 14'
DATE COMPLIANCE ISSUED:
.VARIANCE GRANTED: Yes No
t
ti cr
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P
C(vo.L
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Assessor's office(1st Floor):
Assessor's map and lot number
Conservation(4th Floor)" ` )-� / .S �� °►
Board of Health(3rd flo /v
1< D�31l7'�DL i
Sewage Permit number �TIC "S uEM
w•
Engineering Department(3rd floor): ,.., � �
INSTALLED IN COM •
House number{
Definitive Plan Approved by Planning Board 19 WITH TITLE 5
APPLICATIONS PROCESSED 8:30-8:30 A.M.and 1:00-2 00 P.M.only ENVIRONMENTAL Col).V-Li%y
TOWN OF BARNSTAij
� .�R,A.,.a �. �.:.
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO �C'�'1.S �/'yt�^ �'z ' G`I '►� G"Y�rar-�� Z
TYPE OF CONSTRUCTION
TO THE INSPECTOR OF BUILDINGS:
r
The undersigned hereby applies for a permit according to the
/following information:
/(N L
Location 12 �r• -tom_; L(� r�2 C' �'ti /
Proposed Use L'i C-�.�ct 2 S ��^cj+�j-a, /TUl^y 2 G✓c=;.�l. s'`��'/�
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Zoning District Fire District
Name of Owner ✓ i r �-"'t i-1._S Address i Z ^
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Name of Builder 1'�< <� Address�
Name of Architect i7U h 'z Address C.
Number of Rooms Foundation 0 `�G'cw���� ✓� � '� w,
Exterior 6 �1 f � � Roofing
Floors Qc,'✓%?.'f 6 04(-<°��, Interior IA/-ct l/
Heating Plumbing j�641 Z
1 Zf
Fireplace � ,t�%�%9 Z Approximate Cost j
Area
Diagram of Lot and Building with Dimensions Fee
I't l Gt�t
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable re arding the above construction.
Name
Construction Supervisor's License
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SHEET NO. OF
CALCULATED BY �' DATE
_ BILL CROSTON BUILDING CONTRACTOR �
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BOX 138 - OSTERVILLE, MASSACHUSETTS 02655 CHECKED BY �� !$ DATE Q� le
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