HomeMy WebLinkAbout0149 GROVE STREET - Health 149 Grove Street, Cotuit
— - - - ------ - _-- - ( A= 019-022 � f
i
s
I�
i
4
Commonwealth of Massachusetts
,- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Grove Street _
Property Address
Sherman
Owner Owner's Na e
information is
required for every Cotuit MA 02635 1/7/21
page. Citylrown State Zip Code Date 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.
A. Inspector Information
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
Telephone Number License Number
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
1/7/21
Inspecto Ignature 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
_a
r
i
Commonwealth of Massachusetts
�. ,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner Owner's Name
information is
required for every Cotuit MA 02635 1/7/21
page. Cityrrown 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:
® 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:
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.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 118
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner information is Owner's Name
required for every COtuit MA 02635 1/7/21
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 below):
❑ 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.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
I
Commonwealth of Massachusetts
o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
9 P Y rY
149 Grove Street
Property Address
Sherman
Owner Owner's Name
information is
required for every Cotuit MA 02635 1/7/21
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:
I
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
❑ ® 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
I
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner Owner s Name
information is
required for every COtuit MA 02635 1/7/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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
Commonwealth of Massachusetts
,�p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a
149 Grove Street
Property Address
Sherman
Owner Owner's Name
information is
required for every Cotuit MA 02635 1/7/21
page. Cityrrown 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
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs® El Was of break out?p 9
® ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner Owner's Name
information is
required for every Cotuit MA 02635 1/7/21
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
3 bedroom permit on file at BOH
Number of current residents: 3
Does residence have a garbage grinder? ❑ 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 ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 105 GPD
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o
v 149 Grove Street
Property Address
Sherman
Owner Owner's Name
information is
required for every Cotuit MA 02635 1/7/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
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: Pumped 2018 per owner
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner Owners Name
information is
required for every COtuit MA 02635 1/7/21
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Septic tank 1979, D-box 1999, Leach chambers 1996 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
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.):
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner Owners Name
information is
required for every Cotuit MA 02635 1/7/21
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 10"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
811
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
>2"
>2"
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner information is Owner's Name
required for every Cotuit MA 02635 1/7/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. 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.):
8. 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
t5insp.doc•rev.7/26/2018 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner Owners Name
information is
required for every Cotuit MA 02635 1/7/21
page. Citylrown 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 co of current pumping contract(required). Is co attached? Yes No
P P copy ❑ ❑PY 9
9. Distribution Box(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.):
H-10 D-box is 18" below grade, no adverse conditions observed
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�o
149 Grove Street
Property Address
Sherman
Owner Owner's Name
information is
required for every Cotuit MA 02635 1/7/21
page. Citylrown 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 ❑ 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 6
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
►p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner Owner's Name
information is
required for every Cotuit MA 02635 1/7/21
page. Cityrrown 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 ponding, damp soil, condition of
vegetation, etc.):
Infiltrators were video inspected, hung pert pipe show now signs of past hydraulic failure, the old pert
pipe trench is still in place it is presumed to have failed in the past, bottom of chambers is
approximately 4' below grade
12. 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.):
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Su
bsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 149 Grove Street
Property Address
Sherman
Owner Owner's Name
information is
required for every Cotuit MA 02635 1/7/21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwgalth of Massachusetts
r-
:Title 5 Official Inspection Form
'"Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Grove'Street
Property AddrpSs7
Sherman
Owner Owner's Name
information is
required for every Cotuit MA 02635 1/7/21
page. Cityrrown 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
I
Cal fly` i
G
s17 3 G �� k342p�- -escf�LC
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
149 Grove Street
Property Address
Sherman
Owner Owner's Name
information is
required for every COtuit MA 02635 1/7/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
9'
Estimated depth to high ground water: 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:
previous inspection report from 2019 has augered hole and gw at 10'
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping shows the site at 14'msl and nearby surface water at 5'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 149 Grove Street
Property Address
Sherman
Owner Owners Name
information is
required for every Cotuit MA 02635 1/7/21
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® 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
® 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
p P 9
• I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Apr Q3 2019 11:45 HP Fax page 1
Commonwealth of Massachusetts _Q
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r.0
v 149 Grove Street '
r[;
Property Address
Stephen Wald '
Owner Owner's Na
information is Cotuit V MA 02655 3-28-19 M
Ln
required for 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. Please see completeness checklist at the end of the form.
```�Utll I111 i 1 Np f1////
illingoutformsen fi A. Inspector Information Sly l3�pC0 ,:�`�� •sq�y
on the computer, '��:' JAMES N
use only the tab James D Sears :m
key to move your Name of Inspector
cursor•do not Capewide Enterprises
use the return Company Name
key. 153 Commercial Street �
1 N tStttPt�G�```,`\
V Company Address
Mashpee MA 02649
Clty/Town State Zip Code
low 508-477-8877 S1623
Telephone Number License Number
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); I 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 f
3. ❑ Needs Further Evaluation by the Local Approving Authority
4, ❑ Fails
4-3-19
spectors 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.
t5insp.doc•rev.7f26/2d18 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Apr Q3 2019 11:45 HP Fax page 2
Commonwealth of Massachusetts
Title 5 official Inspection Form
vlt,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
Property Address
Stephen Wald
Owner Owners Name
information is inform every
COtuit
required for eve MA 02655 3-28-19
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:
® 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 is a 1000 Gal Tank D Box and 6 chamber's
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 exfiltraticn 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.
*Am etal 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):
LSinsp.doc-rev.7/262018 TWO 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Apr Q3 2019 11:45 HP Fax page 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
Property Address
Stephen Wald
Owner Owner's Name
information is required for every Cotuit MA 02655 3-28-19
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 below):
❑ 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
15.3030)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment: t
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Apr Q3 2019 11:45 HP Fax page 4
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
149 Grove Street
Property Address
Stephen Wald
Owner Owners Name
information is required for every Cotuit MA 02655 3-28-19
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
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Nnsp.doc rev.7/2512018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 10
Apr Q3 2019 11:45 HP Fax page 5
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
149 Grove Street
Property Address
Stephen Wald
Owner Owners Name
information is
required for every Cotuit MA 02656 3-28-19
page. QtYRo State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑
Static liquid level in the distribution box above outlet inv® art due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in is less than 6"below invert or available volume is less
than 1/day flow �f//.�F
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 S ppm,
provided that no other failure
u e 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-
10,000 gpd.
❑
The system fails. I have determined that one or more of the above failure
® re
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
PP Y
❑ ❑ 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
t5lnsp.doc•rev.7/MO18 Title 5 Official Inspection Form:Subsurface Sewage Oisposaf System•Page 5 or i8
Apr 03 2019 11:46 HP Fax page 6
' Commonwealth
o monwealth of Massachusetts
V5
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
L
Property Address
Stephen Wald
Owner Owners Name
information Is
required for every Cotuit MA 02655 3-28-19
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
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break oui?
❑ 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)1
t5insp.doc-rev.7/202018 Title 50f9cial Inspeclion Forth:Subsurface Sewage Disposal System Page 6 of 18
Apr 03 2019 11:46 HP Fax page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
149 Grove Street
Property Address
Stephen Wald
owner Owners Name
information is CptUit
required for everyMA 02655 3-28-19
page. ►YRown State Zip Code Date of inspection-
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Description:
1000 Gal.Tank D Box and six chamber's.
Number of current residents: 0
Does residence have a garbage grinder? ❑ 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
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse?
❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 2017-15,000Gele
2018-10,000Ga1's i
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
t5in5p.doc•rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Apr 03 2019 11:46 HP Fax page 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
Property Address
Stephen Wald
Owner Owners Name
information is required for every Cotuit MA 02655 3-28-19
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Cammercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seatstpersonslsq.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: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
15insp.doc•rev.7/28/2018 Tile 5 Offidial Inspection Form!Subsurface sewage Disposal System-Page a oils'
Apr 03 2019 11:46 HP Fax page 9
Commonwealth of Massachusetts
PF Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 149 Grove Street
v
Property Address
Stephen Wald
Owner Owners Name
information is required for every
COtUIt MA 02655 3-28-19
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box,soil absorption system
J
❑ . Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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:
Tank NA-Leaching 1996 Permit # 96- 194
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 201,feet
Material of construction:
❑ cast iron ® 40 PVC ®other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting,evidence of leakage,etc.):
Pipeing is 4" PVC SCH -40 3-2019 New Line tank to D Box
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Apr 03 2019 11:46 HP Fax page 10
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
kv,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY 149 Grove Street
Properly Address
Stephen Wald
Dwner Owner's Name
iion is
reequiredquired for every Cotuit MA 02655 3-28-19
page City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
6. Septic Tank(locate on site plan):
Depth below grade: 10,
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: 1000 Gal. Precast H-10
Sludge depth:
• 1"
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined?
Asbuilt-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 10"below grade. Inlet tee wloutlet baffle. No sign of
leakage or over loading.
' t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 10 of 18
Apr 03 2019 11:46 HP Fax page 11
S—, Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
k
v 149 Grove Street
Property Address
Stephen Wald
Owner Owner's Name
information is COtUit
required for every MA 02655 3-28-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑metal ❑fiberglass ❑ polyethylene El 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.):
B. 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
tbinsp.doc•rev.7/26/2018 Title 5 Official Inspection Rum:Subsurface Sewage Disposal System•page 11 of 15
• Apr 03 2019 11:46 HP Fax page 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 149 Grove Street
Property Address
Stephen Wald
Owner Owner's Name
information s Cotuit MA 02655 3-28-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cons.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
I
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
'Attach co of current pumping contract (required). Is co attached? Yes No
PY P P 9 PY ❑ ❑
i
9. Distribution Box(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.):
D Box is 16"x16"-18" below grade w/three lines out. Box is dean and solid. No sign of over loading
or solid carry over.
t5lnsp.doc•rev.72612018 Tine 5 Officlal Inspection=otm:Subsurface Savage Disposal Systam•Page 12 of 1a
Apr p3 2019 11:46 HP Fax page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
149 Grove Street
Property Address
Stephen Wald
Owner Owner's Name
information Is
required
Cotuit MA 02655 3-28-19
requiredd 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 ❑ 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,
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 6
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.71262018 Title 5 Official Inspection Forty:Subsurface Sewage Disposal System-Page 13 of 18
l
Apr 03 2019 11:47 HP Fax page 14
Commonwealth of Massachusetts
e Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
Property Address
Stephen Wald
Owner Owners Name
infortnatlon is
required for every Cotuit MA 02655. 3-28-19
page. citymown 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 ponding, damp soil, condition of
vegetation, etc.):
Leaching is two row's of three cultec per row total of six. Check area and D Box. Camera out lines.
No si n of over loading or solid carry over or holding water.
12. 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.):
t5inap.doc-rev.726/2018 Title 5 Of6tial Inspection Form:Subsurface Sewage Dispo6al System•Page 14 of 10
Apr 03 2019 11:47 HP Fax page 15
4�.\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
v Property Address
Stephen Wald
!R'e'
Owner Owner's Name
information is required for every Cotuit MA 02655 3-28-19
City/Town
page. State Zip Code Date of Inspection
D. System Information (conQ
13. 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.):
t5insp.doc•rev.7/26/2016 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal system•Page 15 o118
Apr 03 2019 11:47 HP Fax page 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
"s 149 Grove Street
Property Address
Stephen Wald
Owner Owner's Name
information is required for every Cotuit MA 02655 3-26-19
page. Cityrrown 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
O
Q
C
3G
t5insp.doc-rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 16 o118
Apr 03 2019 11:47 HP Fax page 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street
Property Address
Stephen Wald
Owner Owner's Name
information is Cotuit
required for every MA 02655 3-28.19
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
NC3
Estimated depth toFigh ground water: 10
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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Auger T.H. 10' no G.W.. Bottom of chamber's at 3r below grade. Bottom of chamber's at T above
T.H. Depth,
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5inW,*x rev.MUMS Title 5 Oflicial Inspection Form:Subsurface S swage Disposal System•Page 17 of 18
- J
Apr 03 2019 11:47 HP Fax page 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Grove Street _
Property Address
Stephen Wald
Owner Owner's Name
information is required for every Cotuit MA 02655 3-28-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® 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
® 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
9RAM 7 A/,
Q"Ire- 3 i
io
t5insp.doc-rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 d 18
No. ��� l 1� j Feef
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_.0000�'
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Misposai *pstem Construction permit
Application for a Permit to Construct( ) Repair()� Upgrade( ) Abandon( ) ❑Complete System Xindividual Components
Location Address or Lot No. ("t'-I GRw ; 5r1 Owner's Name,Address,and Tel.No.
CaTu�"i^ s,C-a� &-�Us� �4UD
Assessor's Map/Parcel 0 i �, Sp Y� V _
Installer's Name,Address,and Tel.No. 509-c -n -U-1-i Designer's Name,Address,and Tel.No.
(WEW(26 QJ �Zff I P-130
*t M
Type of Building:
Dwelling No.of Bedrooms Nh Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �✓�' gpd Design flow provided gpd
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) -s A&)G
S 'L ttY fL `tom
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 Certificate of
Compliance has been issued by this Board of Health.
Signe Date 3715 — L
Application Approved by �_ Date
Application Disapproved by Date
for the following reasons
Permit No. Z01 San Date Issued )/
-------------------------------------------------------------------------------------------------------- -
e� t� x� .,. .,, _r'�...lM .,... r��r-. .. -. y� ��' � .. ... �. ..v'r ,,.r. ?....,�... .r.-. ,• ti ..1 .��� , ;.
No..2101 1 l 4/ 1- Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered incompute
PUBLIC HEALTH DIVISION - TOWN OF'BARNSTABLE, MASSACHUSETTS Yes
01ppfication forwBisposar *pstem Construction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ,Individual Components
Location Address or Lot No. (t 4j GPWC -!5M, P Owner's Name,Address,and Tel.No. f
SA P s� Aoj k.Aca>
Assessor's Map/Parcel G�lq 16-A t�0"��1 t1" ► !L w1
Installer's Name,Address,and Tel.No. ;0$'-1471 te-1-1 Designer's Name,Address,and Tel.No.
4W �t . aN IIt8o N/X
Type of Building:
Dwelling No.of Bedrooms' Lot Size sq.ft. Garbage Grinder( )
Other Type of Building :SI begQT1444, No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) AIW gpd Design flow provided gpd
_ F
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank r Type of S.A.S. t
Description of Soil
Nature of Repairs or Alterations(Answer when applicable): ��
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 Certificate of
Compliance has been issued by this Board of Health.
Signed Date �/"�w5
'Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �, .. �� _ Date Issued
m
�
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal s.stem Constructed( ) Repaired(�) Upgraded( )
Abandoned( )by / N'ri9�PQ(
At - .G X-- -3�' Via"r 01.-r has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ,J)) dated
Installer JJ Y ! v, l
(�iC2[��}1� �'�J! 1kBd Designer jll�,,Q;
#bedrooms /Lt Approved design.flow..
gPd
The issuance of this permit,shall not be construed as a guarantee that the system will-function as'destgn"ed., t
f` Insector t
Date s 77! � � p ,`
- -- - - = - ---- - --' -----` --------------5-------------------------------
No. 0 f Fee gf' 27 av
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at �
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local-provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date 7 17,( 7 t Approved by
.___
lugCommonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of Environmental Protection
One Winter Street, Boston MA 02108 (617)292-5500.
TRUDY CORE
r Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 149 Grove Street, Cotuit,`MA Name of Owner: Donna Parker
Address of Owner: Same
Date of Inspection: September 16, 1999
Name of Inspector: (Please Print) James M. Ford Y
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3iO CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 026SS-0049 Map: 019
Telephone Number: (SO8)862-9400 Parcel: 022
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
✓ Passes
Conditionally Passes
Needs Further Evaluati By the Local Approving Authority .
_ 'ls
Inspector's Signature: Date: September 21, 1999
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days
of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable,and the approving authority.
NOTES AND COMMENTS _
''lf
fit
SE
P
revised 9/2/98 Page Iof11
Primed on Recycled Paper
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
INSPECTION SUMMARY: Check A, B, C, or D.
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or enfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health)
broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of I
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART A
'CERTIFICATION (continued)
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment. "
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)
THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
A
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 AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or,more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of amtnonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
y z..
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
_ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
detennination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than'/z day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
— Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
colifonm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
supply
the system is within 200 feet of a tributary to a surface g water pp y
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
PART B
CHECKLIST
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
Check if the following have been done: You must indicate either-"Yes"`or "No" as to each of the following:'
Yes No
✓ _ Pumping information was provided by the owner, occupant, or Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ As built plans have been obtained and examined. Note if they are not available with N/A.
✓ _ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout. .
✓ _ All system components,excluding the,Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for conditions of baffles
or tees,material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
✓ _ Existing information. For example,Plan at B.O.H. `
✓ _ Determined in the field(if any of the failure criteria related to Part C.is at issue, approximation of distance is unacceptable)
[15.302(3)(b)]
✓ _ . The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
•
revised 9/2/98 Page 5oftt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
Total DESIGN flow n/a
Number of current residents: 4
Garbage grinder(yes or no): No
Laundry(separate system) (yes or no): No ; If yes, separate inspection required
Laundry system inspected(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last two year's usage(gpd): 1998-84,000 pals.; 1997-89,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd(Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no) _
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped on May 7196 per treatment plant.
System pumped as part of inspection(yes or no): No
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic.tank/distribution box/soil absorption system
Single cesspool
_ Overflow cesspool
Privy
_ Shared system(yes or no) (if yes,attach previous inspection records,if any)
_ I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: Cultecs added on May 15196
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
BUILDING SEWER,
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC other(explain) l
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: ✓ "
(locate on site plan)
Depth below grade: 11"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 1000 gal.
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle: 22"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How dimensions were determined: Measuring stick
Comments: "
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) Both of the baffles were present The liquid level was even with the outlet invert. The tank was pumped for
maintenance.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: concrete metal _Fiberglass Polyethylene _other(explain)
Dirensions:
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:
Connnents: T
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7of11
'_
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
TIGHT OR HOLDING TANK: None.(Tank must be pumped prior to, or at time,of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) The D-box had a hole in it.
A new D-box was installed-see permit#99-613
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION YORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length: 2 systems (new system added 8'x 25'in 1996-per as built card)
leaching fields,number,dimensions:
overflow cesspool,number: '
Alternative system
Name of Technology:
Comments-
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation,etc.)
The leach field was not dug up.' There were no signs of failure in the D-box. The bottom to grade was 3'6".
i
CESSPOOLS: None
(locate on site plan) ,
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: x:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection).
• F tc. I
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
Map: 019
Parcel: 022
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
A�
i
d O
Q
C
A l - /(o
81 • I
Aa- aoO
3 Ci ct - 13
C 3
f33- 30
O -r-0
14014,
Grove sT
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 149 Grove Street, Cotuit, MA
Owner: Donna Parker
Date of Inspection: September 16, 1999
NRCS Report name
Soil Type
Typical depth to groundwater '
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar '
Shallow wells
Estimated Depth to Groundwater 9 Feet ,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
✓ Observed Site(Abutting property,observation hole,basement sump etc.) 4
Determined from local conditions
Checked with local Board of Health
Checked FEMA Maps
Checked pumping records -
Check local excavators,installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Hand augered down to groundwater which was 9'below grade. Using the Cape Cod Commission Technical Bulletin, the
high groundwater adjustment for this site (M1 W 29, Zone A, 7199)was 2.4'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not warranty
or guarantee that the system will function properly in the future. There-have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report. r
t
revised 9/2/98 Page ltof11
TOWN OF BARNSTABLE
LOCATION H 6 e-OVe— 'Sr SEWAGE # C1 - 19q
VILLAGE CD UT ASSESSOR'S MAP &LOT 019- 03oL
INSTALLER'S NAME&PHONE NO. Goy Co,-, 'Iumpos
SEPTIC TANK CAPACITY I CJZTb
LEACHING FACILITY: (type)S U fCG (size) �X oZS
NO.OF BEDROOMS 3
BUILDER OR OWNER b0nAA PAekEf-
PERMUDATE: 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 lua A 6 (�j�.
A�
a
c
Al - 1(0
3 f3i- 1 lv
Aa- 2010
83 - 30.
C3- 30
TOWN OF BARNSTABLE
LOCATION SEWAGE 1 U O
VILLAGE C(u � � ASSESSOR'S MAP & LOT l C
INSTALLER'S NAME&PHON_E 140. C6&C � uMDc�r' ' �(�8, 2620
SEPTIC TANK CAPACITY 60 6 ;
LEACHING FACILITY: (type) Cv ITOO (size) P X
NO.OF BEDROOMS 3
BUILDER OR OWNER 6h() r-N, ArUq—
PERMITDATE: <iof6 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by 4 fi- to"
e _
f
17
Zo
tk e
133,
LOFCATION ® V ' 'SEWAGE .PERMIT NO.
VILLAG X `
INSTA ER'S NAME &,4 ADDRESS
Cyr ' z21 Z.5
B U I*L D E R 4R. 0 WVo ER
DATE PERMIT ISSUED .
DIAT -E COMPLIANCE ISSUED
{
46
No. ��y
L (� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
�1 _ U' aZ. es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for W5pool *p6tem Construction Permit
Application for a Permit to Construct(WRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. I� v S9 . Owner's Name,Addr ss andd,T No.
Assessor's Map/Parcel
, � 1 .
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.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) � � �
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 issu thiWBof Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
r. No. / / - (�f/ Fee
J v .6 a.L. THE COMMONWEALTH OF MASSACHUSET;TS f Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS es
Zlpprication for Oigozar *pztem Congtruction Permit
Application for a-Permit to Construct(Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No./'1� r S Owner's Name,Add:INNrgss an .No. /�
Assessor'sMap/Parcel C.+v C / A/v !°r /1 ci0—
"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 Y Number of sheets Revision Date
Title
Size of Septic Tank .' Type bf S.A.S.
Description of Soil—
;.
Nature of Repairs or Alterations(Answer when applicable) Alt tt.l 4// �,✓✓ X C26.V 4e..
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 is y this BjW4 of Health.
Signed ? LiCS Date /
Application Approved by Date
Application Disapproved;for the following reasons
Permit No. ��- �'� Date Issued;
THE COMMONWEALTH OF MASSACHUSETTS
G � BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewa. a Disposal System Constructed( Repaired( )Upgraded( )
Abandoned( )by
at 67 has been constructed in accordance
with the provisions of e 5 and the for Disposal System Construction Permit No. - dated
Installer Designer
The is
mit,sh/all of be construed as a guarantee that the system will functions de ign�j"d. .,
Date ri' f Inspectorr* 'i' � �t�
--------------------------------
No. �7 V Fee �5
i
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwizpozar *pMem Conotruction Permit
Permission is hereby granted to Construct )Repair( )Upgrade( )Abandon( )
System located at
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 be completed within three years of the date of this permit.
Date:_ 2 7- 2,9 Approved by .
Ll
N _ Fee
o.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS l f
01pplication for Mizpooar 6potem Con5truction Permit
Application is hereby made for a Permit to Construct( )or Repair(VI'an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
+� �AVi���erz
GroV--r-s> 0o��,
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
(�O a00ra"�Mpu.s
Type of Building:
Dwelling No.of Bedrooms 3 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
Description of Soil
� r�
Nature of Repairs or Alterations(Answer when applicable) U /90 ti T( ��CW
0o0 en To ex t f/e7 ae2 ry
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the a ore escribed 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 this Bo d of He It r
Signed Date P"J /3/ t
Application Approved by T -_
Application Disapproved for the following reasons
Permit No. % l /q Date Issued .� ,76
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
ti
Certificate of (Compliance
THIS IS TO C RTIFY,that the On-site Sewage Disposal System installed( )9r repaired/replaced(lam)on
by for ✓/ o
as - �'' `�'�' .»d has,been construoted inmecordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. iO '' dated
Use of this system is conditioned on compliance with the provisions set forth below:
d
a"-� --_------- ---------- _--_- ----------- - ---
Fee 43—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migozar *p5tem Cow5truction Permit
Permission is hereby granted to G .ti73u✓� u�
to construct( )repair(t/)an On-site Sewage System located at
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 condition
All construction m st be completed within two years of the date below.
Date: aJ Approved by
06
No Fee
A "
THE COMMONWEALTH OF MASSACHUSE17S
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[ppYtcation for,piqogar *pgtem Cougtruction Perron _
Application is hereby made for a Permit to Construct( )or Repair(k-lan On-site Sewage Disposal System at:
4 Location Address or Lot No. Owner's Name,Address and Tel.No.
4 � Vc0�� roc e T Po"1)14 �2 y
�.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
016 aD,rn�v V, tv EJRn �Ca1.
I
� o����u�l1e y�8-s6�r6
Type of Building:
Dwelling No.of Bedrooms 3 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
WJ
Description of Soil
i
Nature of Repairs or Alterations(Answer when applicable) 41061L'00 C 490 ixa,•,1 1=t&1
✓>e} ci /O rx(1%/-7 L"aJA 1 1? .) /U✓C
Date last inspected: l wS
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 this Bo d of He It
j
Signed Date
Application Approved by 5 3
Application Disapproved for the following reasons
Permit No. 7 (� ��� Date Issued J� 3 ��
Ahe- h oI C J •CI
) 41
10
64
t 10 .7 \ L 7 ':--Ale14
�:•r } =� FKP.+'✓S. .o � 4�r�' pQ�L_AEI '�: s.
P
s
• i r is-'( ! - ;., iC t ,f
LEGEND 0,ERTIFIE PLOT` PLA11 ' .r
EXISTING SPOT ELEVATION 0 ,0 s cS,5c7/rSi �AP Lor ,
EXISTING CONTOUR - - - 0 .,qvr. Sr;
FINISHED SPOT ELEVATION ., 0.-9(
FINISHED CONTC UR - _ 0 CO /!�/T:;;...`. .IN
APPROVED : . I
APPROVED = BOARD OF HEALTH JIM S.fA'S � g, U A SSo
_.. SC,aLE 1 '! ¢U DATE '7
DATE ----' GENT _ _ _ — ..
IELDREDGE ENG'NEERING Co. INe-' CLIENT AK 1 CERTIFY THAT 'THE PROPOSED
( EGISTEREI �RFGISTEREDII JOB NO. 7Fl/ l3 BUILDING SHOWN ' ON THIS' `PLAN
CIVIL ! LAND CONFORMS TO THE ZONING' ..LAWS
�EN.GINEERS, DR. BY f1
' i.•,S,URVEYOR-SJ �= OF BARNS 6 E , MASS.
33 NC' MAIN ST 712 MAIN 711 CH. BY: .T1___.7'--
M 111 MA:i;;. HYANNIS MA'': ; /
SO.. YAR Ou SHEET -__.- OF 0 TE EG. LAND SURVEYOR
/C TAN.
20fT. M/N• 7W /2 /NCNES QELOW GRADE, A 24
ATE/? CO/VG-RATE COVER ShfALL
o/f1 M V Y
Cf•1 AN .EXlro" HEA
0
RA OE.
" T
/O FT. /`'1/N• „ _ 9,E BROUC,HT /ygLL a lJ.SEAP
VE S
P/PE Co R
¢ PVG /RO/�
�. CA ST
N. P`1 490
CONCRETE M/ / ) OR/VE wA
ao DOveLE
EL. /O7�•O COVERSFT. j
2� M/N:CJeADEX I'1�L P/PE
..• - �S 3 0 o S, i
I
:O L/lJIJ/O LCVE L. ALL SO/L L70WAl
TO
LS f7-;6 PERCo L.A7 o • ArCeAL_ 'TOBEREf" CASTw • � REF/LLED
,q7w P/ lociOa� /+VEO AND
- N K • u . ' r o v iq S SNCI Y/Y.
?ADULATION
a • I• 0 n ♦ p n , ;
. t. a ! Q • � v o . � a/MEN FT
SECT/O N Or a A . ' d • o/noENs/oN 8
,....g.l .SYSTEM Lam./' -f7 rr7-�Ao �.Tr�T71 C 4-- Fr
SEWAGL D/SPQ•S��- r. .S J/HENS
LEACHING TRENCH ,� D/MENS/ON D S FT
PERCOLAT/a V M.oTE�/'4 L
I 1 E D/HENS/ONE ---
n
cr: . 9o• S -� -- SO/L LDG
I TEST
O"/
S ! TEST !,
r'
/7 PC /
-j/8•I✓ASHEJ /PcSv 7SW./TNESSEOBY R_r� I?��i,�c/S n r, �_ Z ' G
104 O +..•. + ,• a, • S ONE i.:AT/ONR�ITE � c . — �..i�So �- 5✓fit c
• ♦ • n • PER C= v /y/N./INCH �; - r
�. � .• �-- 4"couBc• pERC.-l�T/O'NRATEI� 2
• o • ••i� •' • ►� PERFORATED
A.
14 e . WASHED r 3
e t M p.c. QEOROOM S (
. p p •.� $"TONE � NrJ. BER 1� a • •� GLARBAGE ?/SPOSA L UN T
a • '573-''oCsA
Gr�L�o
w S // ATED FLO � oun!
SU/TABLE FT.
PERCOI-ATtOhf EACH/NGARA
.-
n vI14. 7 E!2E::==
•-
f M.,T�:r AL S4.fT
• RE,.�ERVE AREA
,SECT IO N X"x NO GROUNU WATER ENCOUN?EREL
SCALE : 1/4~ - - �•• ❑ GROUND WATER AT Ez-JTV•i �
-�-'
.�:..,;:•,..� //V VE14.1'ELEI/AT/O/1/S �t ssr- ;s u rz .:""MA �r
/NVERr "C7 T/I/ T
ROBERT ?•4 FT•
%
r J /NLET SE:�/C TANK
<< P. r". 7.Z�7
;,c o -,......... EL DREDGE'HN4S1 4rSR/N6
v .......,..�
• pUT�ET SEPT/C Ts1/vK' b �F7..
NO.22162 O ti y INLET D/S7R/BUT/ON Bo}� ��`— HYANN/T MASS. SO. YARMouTfl, MAS-s
,�� � l -y/p MA ST. 33 No•r1AIN ST.
Ay0 GIS,E .�`�
p tJ7LET 0/STR/B!/7/ON Sac �t -FT,
fDAL F3`G END O F L EACH/NG TREN GK FT .10 9 N O. Sf/EAT ZO F Z.
-7g'_ /Z 1C E
No................_....... Fxs.... ....._...:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
..... 41 u' --------------OF....... ..... .�:.. ...!. . '�� ._.................
Appliration for Disposal Works Tonstrnrtion rr it
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy. at H .---.... .... .. 7.. ... e ...................... ........ .--•-•-•-------- .._........ ..-----------------......---------_....
�A2r Af
3
ation- dress or t�o.
wn r Address
a ........... i •..... .. .... . .. .. ..4............................ --•••---------------•............-•••--..... .._......--•-••-•--•--•._............._-----...
Instal er 67 Address
d Type of Building Size Lot...3:.�!._`��------ feet
U Dwelling—No. of Bedrooms. ............ _ -----_------___.-_-Expansion-Attic ( ) Garbage Grinder ( )
aOther—Type of Building .� /k� _ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures --------------- --------------•----- ......
W Design Flow.............. ................ ........gallons per l per day. Total daily flow..............3. .....................gallons.
9 Septic Tank—Liquid'capacity./�®gallons Length.__......... Width........... Diameter................ DeQth......3.-e _.._.
. J
x Disposal Trench—No.__.______/..._____. Width_____.,,.__..._.. Total Length._.._It'. .... Total leaching area_ ....... .....sq. ft.'
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (1,< Dosing tanjh
Percolation Test Results Perform .................... Date.......
a / .
a
,..a Test Pit No. 1... a.._.minutes per inch Depth of Test Pit-----------........ Depth to ground water...... ................
(1 Test Pit No. 2................minutes per inch Depth of Test Pit..... '.;S_._ Depth to ground water___--_-
a -----••. --•-- - -
O Description of Soil b. �.`^... ...... `.��'.sc< .-�-�----�e�-.....................................
U .....-------••------•---•-•-----•-----...-•----------•--------------------------------------------=--------------------------------------•---------------.........---............---••------...---.......
W
•-•---------------•----•----------•--•--••-------------••----------•---•--•------•--------.-----••----•-------------------------------•------------------..........----....--•--------•---•...........
U Nature of Repairs or Alterations—Answer when applicable...._......................................................:....................................
...........•. .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until.a Certificate of Compliance has been is ed by the board of health.
Signed. . .A �.. /Z 6 7
D'!
ApplicationApproved By------.. .....................• --------------•-•--•---•-••••-•..__..••-••---•---••-
Da te
Application Disapproved for the following reasons:----•------------•--------------------------------------------------------------------------------------------_
--••-----•-•----•-----......-•---------•----••-------------------•-•--------------........--•----•-••------------------••--------------.....----•••---•-------•--------••---•------------------•••------
Date
. .
Permit No.---..... .` .................................. Issued.......................................................
Date
` bb�
No........................ Fims.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...----....................................O F.......................:..................._..........-
:. Appliration for Uiipnsa1 Works Tonstrn.r#ion Famit
, a ,,
A f lication is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
PP Y ( ) P ( ) g p
System at:
....... ....__......_.......... ........................... ......------------------------. -•--•••--.....---........................
a Location•Address or Lot No.
......................_........................Owner-- - •. Address
---•••.........................•.... ••-•.....--•••---•--•--•.........----•........L•---.....-----•......................_.........--
W
Installer- Address
Type of Building Size Lot............................Sq. feet
�., Dwelling'—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p`4 Other—Type of Building ............................ No. of persons_ Showers;(" ) Cafeteria ( )
Other fixtures ---•----------------•-..........-•-•--•-----•. ..r04
.............
----- -----------
•-•-------------
W Design Flow............................................gallons per person per day. Total daily flow.._................_......................._gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..............:...... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'., Percolation Test Results Performed bY.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a, ...............................................................................••-•--•......••..............................................................
ODescription of Soil......................................................................................................................................
U
...
VNature of Repairs or Alteration's—Answer when applicable...............................................................................................
-•••----•-------•---------••--------------------------••--••--•-------------•--•---••-•-----•-••-----.........--------••---•-•-•----•--•------------------•-------•------------------......_••••••-•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:iT`.
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ..........................
Date
ApplicationApproved By...... .114................................................................................
Date
Application Disapproved for the following reasons-------------•--------------••--•----......--•----------------•---------------•-•----------------•-•-------•••---
............................................•-------•----•--•----•---•-••--•--------:..----••----•--••------.........--•---•••------••-•------•----------•-•-•------------•••-------••---••------•.••-•-
Date
PermitNo.......... ................................. Issued...........................................Date
Date
THE' COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0 F........./17! .........................................
Tntifirate of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�) or Repaired
by..........I...........C.41f-2Ft...
...............................................................................................................................
Installer
at.............
------------------------------------*-----------------------*.......... .........-...................�:....................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction P8rmit No....... ....................... dated------114ft- - -1,1.................
Ar-Mc, I dfiE CONSTRUED AS A GUARANTEE THAT THE
THE ISSUANCE OF THIS CERTIFICATE SH
SYSTEM 'WILL FUNCTION SATISFACTORY.
DATE-----.:..... . .... ................... Inspector....._............................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF,'-"FflkALTH
... . ......OF............... .. .................. .........................................
No.......... ..7.2f ......................... ..... .. FEE........J-4n."
Dispsal Works TI-Instrurtion "parAft
Permission is hereby granted.............ellrtF...............V/4' .......................................................................
....................
to Construct ( %) or Repair an Individual Sewage Disposal Sfiftem
atNo. Lo.. ........... c- ----------- ---------------------------Street
- ." I Permit W Works ConstructionT " it No......Ai... Dated..____..............
as shown on the application for-Dis
POS
.......................................................................................................
Board of Health
DATE.
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
P
/{ Hsu+
Y
394E-2—. -
N•
Q
$ 10
'
Zt
64
-46
, L l ... 4,1 1 ^ 3•yy
/s �
ilk
{ sir 1V .. f 4
� n
z rsrzt TrzEA/c
b {
•:Y1 Of A.ISMBERT
,
A
9�oD
1.
T.
f 3 t
19 ; EXISTING" SPOT . ELEVATION! ` Ox0 CEFZTIFIED., PLO Pt AM
s : EXISTN-G.- C0N,TOUR —
�i~!Nf`SH'E®"`SPO'T ELEV'A}T I'd
RJ) ` 0r� Ire ' n ssc-S>OrcS�M�i� i �'LG � �,
� aN SNE°0,...00NTOUR --- 0 '
tit APPROVED 1' BOARD Y
OF HEALTH IPd
' A 1
TE . L�- AGENT -- — ---- ��
' SCALE ' 1
�_,IREDGE ENGINEERING CO. IN
CLIENT . .
' [REGISTERED
CERTIFY THAT THI PRd? O$0U p EGSTERE «
r CIVIL LAND JOB NO. - �L3__ BUILDING SHOWN ON H15 #:LAM
t! ' ' CONFORMS TO THE Z( MING LA1 �_
.. NCriNER SURVEYOR DR. BY i �4 i} . ,OF BARNS B E , MASS .
'33 NO' MAIN ST 712 MAIN ST CH. BY: IZ
S0YARM OUT H, MASS. HYANNIS, MAST. / 71
, ,.
SHEET_ OF
DX EG. LAPI®. SURE�i' "I g ;
,r _ , ..... .. Vim• •N� .tom �; •
/ a
r NO /F THE• SeP7-1 G' 'T.A n/k /Jr /�O Inc E
/, ; } - • 2®F7: M/.-v ,,. 7."; g,04®/iV OAA®E, .A 24 -
'ter 1^ CH 10/A/�9ETE/?# CONCFe'ET�` COVER 5'f%ALL
� • �.E ®RO tJG,HT `7"c� a sT6 ®�. �Q.a M —SXTED�/hrE4 /Y
4"PVC COVR EUF /n/
6A JT//a0/VE �A7AzL
EL, co VIERS
® 4"DOUBLE
27. MrN:64ADEx r. /Clvc P/PE
C4EA/V_SAND
ALC SO/L ,OOK/N TO
4- CAST pr ' JMA
U17 3'gLE PE,QCOLAT//✓G
�1, ° ®e A. 0 7 EA-IAL TO46F RE—
/RdA! P/PE ( � L9 O GL o aM/n/•IP/TC'H / SL—
-
PT/C 7.4.v� � `yOVEO ANO REF/LLEO
:. 4PER FT_ BOX e ` e • O `. a ` A . r ao ®� e e AS SHd4Y/N.
1
.'• g ° WASHED o ' 1 7A U p q 0 H
SECT/ON 0F p 0 .n®� ® ° � °p v^�o o ° o , ems,•a ✓"•`
TYSM. O/HEvs/OMScWAGC ®/5P ¢ FT
FT
L,EA�'H//49� T�E/!/�+� SU/TiagLB i D/MEl1(S/0/V �
SCA I-E �4 I _ /'—O PER COLAT/a��/d1.ATFI�/.4 L D/ME/YS/O/Y ® 6/ S FT,
GRO U,V 0 WATEiQ -rA
D/MEAIS/O/V FT.
,CL,eAA1,, TEST*2
L TEST #9�S O/L /
LAYER 4F l l ? ELEV• 00
•? � �i:To:� 3 s� !�8" 3/8°WR5HEO
DATE OF SO/L TEST r/`ELEV. �'
�';o" o • ' t Qr= a $TONE RE 5,v47-_5 W/TNESSED BY R, P, Z3uN/he 15
° " 4„oouSLE PERCc�._AT/ONR�TE / Sc
L-0AM Loan n1
e o � oa .+ . ZO / SriSa�L Su/bSotL
° o °o P�Re-OAATEO PEl?G)z-AT/oA1 FYATE� 2 M/{V., /NCH /3'I
� a ° • WASHED • �' �'u TV►T ��•�
° NUMBEiP OF BEOI('OOM S 3 s�*"�o S
!/,v 1 T I 5
SU/TA,QLE EST/MATED FLOW 3 L GAZ.-IVAY EL, 9p, 5 L� 9
�dE,?coLA7 EOM -2-7 S O. FT. i GR o v ni _ �0
MA7",ERLAI- LEACH/NG o4AF T
c L-.j -f�2
v ECT�®N X®X R ES ER✓E AREA T. f
/ '- O" NO G�gOU/VO WATER ENCOU/VTEREG
6A l'UN 0 WA eA- AT ELEV. D,S
�M l A 5S sor< G�?o✓E ST
s ���j�q�• S,9
C--O 7-v> 7-
//VVE�er ,qT Bu/�v//v0 7, �.7
Q ROBERT �� . ..
P. n, /Ni--=7'SEPT/C TA/Vai'
p BUNIKIS H , OUTLET .SEPT/G TA/VK � �L No.:22162 ��E06E
` 4 � +• //1/¢ET D%S•Y /19UT/oN, S®X ` b.�F?.
7/2 MA/N SY 3 NB..MA V ST,a.
t A a 'GIST
DfSrRIOUT/O/S/_B:.y. _� C -a41,
_S SO.:yi1R�!louTH, MASS.
LA..A
do W O. -] $f l l:3 ,5H@ET Z®F, Z
_� f. IT, "TJ.O 7? 1C GP!