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HomeMy WebLinkAbout0138 GUIMQUISSETT ROAD - Health 138 Guimquissett Road - - --- - - -- -- - - - --- A = 019 160 pug 20 1410:38p p.1 Commonwealth of Massachusetts 4 . MEN Title 5 Official Inspection Form" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road Property Address Richard Clement Owner Owner's Name information is 02635required for every 8-13-14 page. Cityrrown State- Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forrns may not be altered in any way. Please see completeness checklist at the end of the form. :; a Important:When �z ' filling out forms A. General Information ``\`„p�uuu„►,,,,�� on the computer, d OF ngAs use only the tab Inspector.. , 1 2; y key to move your r 3 JAMES 'u'cursor-do not James D. Sears r = = el� 3 kethe velum Name of Inspector a c� y. CapewideEnterprises,LL'C �'•. o:�� Company Name a �.,�� �F•.... 'G "� 153 Commercial Street r. %.,,,,Sr„N 5r1`E`v01 Company Address r Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number a B. Certification . : I certify that I have personally inspected'the sewage disposal system at this address and that the . information reported below is true, accurate and complete as of the time'of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310,CMR 15.000). The system: y ® Passes . ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority a rid 8-20-14 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flowof 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP_ The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "*"This report only describes conditions at the time of inspection and under the conditions of use ' at that time.This inspection does not address how the system will perform in the future-under the same or different conditions of use. /sj Mrs•3n3 TUIe s orficiai ins on nn:Suwsurteee Swage Dlspoaeem•Page 1 of 17 Aug 201410:38p p.2 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- , 138 Guimquissett Road Property Address Richard Clement Owner Owner's Name information is required for every Cotuit MA 02635. • 8-13-14 Page. CilylTown State Zip Code Date of Inspection B. Certification {coat.} - Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: have not found information i ® ormation w •hlch indicates a es that an of the failure e trite -a`y n described in 310 CMR 15.303 or in 310 CMR 15.304 exist: Any failure criteria not evaluated are' indicated below. Comments: - " II 1000 Gal tank D Box and five infiltrators. Note: Old system still tied in to tank. Should be taped off and back filled. , 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. ; Check the box for"yes",f`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 tankJs 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. Q Y ❑ N 4 0 ND (Explain below): 4. 15irs•3it 3 _ _ Title 5 Official Inspection Forth_Subsurface sewage Disposal system•page 2 of 17 Aug 201410:38p I Z p.3 Commonwealth of Massachusetts Title 5. 0fficial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road Property Address Richard Clement ' Owner Owner's Name required for every information Cotuit MA 02635 a, 8-13-14 _ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.), ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpstalarms are repaired. ' B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken 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): C) Fuither Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health.in order to determine if the system is failing to protect public health, safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a`manner which will protect public health, safety and the environment: ❑. Cesspool or privy is within 50 feet of a surface water . ❑ "Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15in7•3113 -ride 5 Official InspeGion Form:Subsurface Sewage Disposal System•Page 3 of 17 Aug 20 1410:38p pA Commonwealth of Massachusetts Title 5 Official . Inspection Fora a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road Property Address Richard a d Clement Owner Owner's Name - information is required for every Cotuit MA 02635 8-13-14 page. city/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) andthe 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 106 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: Y 3. Other x . D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No . ❑ _ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ El ; ® 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 y ❑ ® LiquiddepthinesqqmW is less than 6"below invert or'available volume is less than Y2 day flow /-E,4 e111 vG' t5ins•3113 Title 5 official trrspecrion Forrm Subsurface Sewage Disposal System•Page 4 of 17 Aug 20 14 10:39p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road - Property Address - �, . Richard Clement Owner Owners Name information is required for every Cotuit - MA 02635 8-13-14 page. City/Town State Zip Code Date of Inspedion B. Certification (cont.) a, Yes No ❑ ® 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 be high ground water elevation. 13 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - f - . ❑ 0 ": Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ .. ® _ 10,000gpd. ❑ ® The system falls. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303'therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure., E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply O ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—iWPA)or a mapped Zone ll of a public water supply well- , If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large - ' system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Mns•3113 „ Title 5 OfBdal Inspecion Form:SubsurleceSewage Dispoial System•Page 5 of 17 Aug 20 1410:39p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 Guimq uissett Road Property Address Richard Clement Owner owners Name information is required for every Cotuit MA 02635 8-13-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the'owner, occupant, or Board of Health ❑ ®_ Were any of the-system components pumped out in the previous two weeks? ® El 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? . ® ❑ ,Were all system components, excluding the SAS,•located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ 0, 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)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 15ins•3/13 Title 5 Official hspecrtonjFOM&bwrface Sewage Disposal System•Papa 8 of 17 s Aug 20 1410:39p p 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary,Assessments 138 Guimquissett Road Property Address Richard Clement ; Owner Owner's Name F. information is Cotuit MA ` 02635' " ;'8-13-14 required for every page. City[Town State .- .Zip Cade Date of Inspection D. System Information Description: The system is a 1000 Gal.tank D Box and five infiltrators. i • Number of current residents: 2 Does residence have a garbage jrinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No information in this report.) Laundry system inspected?� El Yes ® No . Seasonal use?r ❑ Yes ® No Water meter readings, if last 2 ears usage 2012-65,000Gais g ( y g (gPd)) 2013-57,000 Gal's Detail: Sump pump? ❑ Yes ® No Last date of-occupancy: '' Present Date Commercial/lndustrial Flow Conditions: _ Type of Establishment: Design flow(based on 310 CMR 15.203): :r Gallons per day(gpd) Basis of design flow(seats/pe.rsons/sq•ft., etc_)'` Grease trap present? • , El Yes ❑ No , Industrial waste holding tank present? , El- Yes ❑ No Non-sanitary waste discharged to the Tide 5 system? ❑: Yes ❑ No Water meter readings, if available: F 6rt,•3113 Title 5 Offlolsl Inspedon Farm:Suburreoe Sewage Disposal System•Page 7 of 17 . Aug 20 1410:40p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road Property Address Richard Clement Owner Owner's Name ` information is required for every Cotuit r MA " 02635 8-13-14 page. CityrTown State Zip Code Date of Inspection D. System Information(cont.) Last date of occupancy/use:.: t, Date Other(describe below): General Information Pumping Records: t - Source of information: NA Y Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped:'_ .. gallons How was quantity pumped determined? h. Reason for pumping: Tyne of System: . ® - Septic tank, distribution box,Nsoil absorption system ❑ Single cesspool j ❑ 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): t5icrs•3/13 _ II „ Title 50frrdal Ins tron Form:Subsurface r r pec a®Sewage Disposal System-Page B of 17 t Aug 20 1410:40p ;. ,a p.9 Commonwealth of Massachusetts " Title 5 official Inspection Form' , ; '- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road Property Address Richard Clement Owner Owner's Name , information is required for every Cotuit MA 02635 8-13-14 page. Cityfrown State Zip Code Date of Inspection D. System Information. (cont.). Approximate age of all components, date installed (if known) and source of information: 2004 Permit#2004 -226. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: Y -,, ., 20" filet Material of construction: ❑cast iron ® 40 PVC ❑'other (explain): Distance from private water supply well or suction line: few _- - Comments(on condition of joints,venting,evidence of leakage, etc.): Pipeing is 4"PVC SCH 40. F _ Septic Tank (locate on site,plan): - Depth below grade: feet Material of construction: ® concrete r ❑ 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 1000 Gal. Precast H-10 Dimensions: T Sludge depth: 211s Mns-3tt 3 ' i TWe 5 Official Inspection Fomr.Subsuface Sewage Dlsposat System•Page 9 or 17 f - Aug 20 1410:40p p.10 commonwealth of Massachusetts ; v, Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 Guimquisse_tt Road Property Address '- Richard Clement Owner Owners Name information is required for every Cotuit MA 02635 &13-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) _. Septic Tank(conL) " Distance from top of sludge to bottom of outlet tee or baffle ?S" Scum thickness � Distance from top of scum tc top of outlet tee or baffle 81' 17" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 8" below grade. In' and outlet tee's. No sign of leakage or over loading. Note: Line to old leaching still tied into tank w/no tee. Line should be caped off. Grease Trap(locate on site plan): t Depth below grade: feet Material of construction: - 0 concrete, ❑ metal [�fiberglass polyethylene❑ pol eth " y y [] other(explain): Dimensions: " fy 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 tsins•3113 Title 5 Ovdat Inspection Form:Subsurface Sewage Disposal System•Page 10 or 17 Aug 20 14 10:41 p p.11 Commonwealth of Massachusetts v " Title 5 Official Inspection Form s = Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road Property Address = Richard Clement Owner Owner's Name information is It1U required for every C0 MA 02635 B-13-14 page. CitylTown State Zip Code t,.R', Date of Inspection D. System Information (cont.), Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): If Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: w4 ... ❑concrete ` ❑ metal ❑ fiberglass ❑polyethylene - ❑other(explain): Dimensions- Capacity: ; gallons Design Flow. ; {. . gallons per day Alarm present: ❑ Yes ❑ No _ Alarm level: ' Alarm in working order: - ❑ Yes ❑ No Date of last pumping:- Date Comments(condition of alarm and float switches, etc.): = , ` A A Attach copy of current pumping contract(required). Is copy attached? ❑.1Yes , ❑ No 115"•3113 _ Title 5 Official Inspection Form:Subsuftoe Sewage Disposal System-Page 11 O l7 Aug 20 14 10:41 p p.12 e _ Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'f 138 Guimguissett Road ' Property Address - Richard Clement Owner Owner's Name information is required for every Cotuit MA 02635- 8-13-14, page. City/Town State Zip Code 'Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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"xl6"-3' Below grade w/cover at 18". Box is clean and solid w/one line out. No sign of over loading or solid carry over. A. 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. . Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: r • ♦, s . - t - x t5lns 3/13 Title 5 OfOdel Insp"an Forth:SUMWEIce Sewage Disposal Systam•Page 12 of 17 � a Aug 20 1410:41 p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road Property Address e Richard Clement t° Owner Owner's Name information is , required for every Cotuit MA' 02635 8-13-14 page, Citylrown State Zip Code Date of Inspedion D. System Information (cont.) " „r Type: ❑. leaching pits number: ® leaching chambers number:~ . 5 ❑ leaching galleries number': ❑ leaching trenches number, length: ❑ leaching fields �i. number, dimensions. ❑ overflow cesspool number ❑ innovative/alternative system Typeiname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is six H2O HiRCap infiltrators wiW stone. Camera out to chambers..Chambers are clean and wet bottom. No sign of holding.water. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration a` 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 t5ens•3113 - •, Title 5 official Irwpec ian Form:Subsurface Sewage Disposal System•Page 13 of 17 Aug 201410:42p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road Properly Address Richard Clement " Owner Owners Name information is required for every Cotuit MA 02635 8-13-14 page. cityrrown State Zip Code Date of Inspection D. System Information,(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): s i 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.): 15ins•3l13 We 5 Official Inspection Form Subsurface Sewage psposal System•Pap 14 of 17 r. Aug 20 1410:42p p.15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Guimquissett Road Property Address . Richard Clement Owner Owner's Name information is ` required for every Cotuit MA 02635 8-13-14 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells 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 13 (3_)oozT=Sy N-Z 5)'5/£pl Boat' 37 P t5ins-3113 Title 5 Offldel Inspection Form:Subanface Sewage Dfa wl System•Page 15 of 17 Aug 20 1410:42p p.16 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y r , 138 Guimquissett Road Property Address Richard Clement Owner Owners Name _ information is required for every Cotuit 'MA 02635` 8-13-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: R, ❑ Check Slope ._ ❑ Surface water ` ❑ Check cellar ❑ Shallow wells Estimated depth t high ground water: fleet; Please indicate all methods used to determine the high ground water elevation:. ® Obtained from system design plans on record 2-04 If checked, date of design plan,reviewed: Date Dale , ❑ Observed site(abutting propertylobservation'hole within 150 feet of SAS) El Checked with local Board of Health-explain: t ❑ Checked with local excavators, installers-(attach documentation)` ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design plan 5-2-04 no G.W. at 12'. Bottom'of chambers at 7'above T H Depth Before filing this Inspection Report, please see Report Completeness Checklist on.next page. ISins•3r13 'TMe 5 Otliaal lnspeclion Fort$rbsurfaoe Sewage Disposal system Page+16-of 17 Aug 20 1410:43p T p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 Guimquissett Road Property Address . Richard Clement Owner Owner's Name information is # required for every Cotuit MA 02635 ` 8-13-14 page. City/Town state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file c { f5ins•3/13 y Title 6 OHldal InspecOm Form:Subsurface Sewage Disposal System•page 17 of 17 r Y � w. TOWN OF BARNSTABLE cc, LOCATION Gly v isge' t( 094 SEWAGE #C9 VILLAGE C t t ASSESSOR'S MAP & LOT 1 INSTALLER'S NAME&PHONE NO. tqa2.G v ,S f SEPTIC TANK CAPACITY kJou 4,1 6t A)" LEACHING FACILITY: (type) 3,l N `Z fog ( ( (size) / k NO.OF BEDROOMS ( � Q n BUILDER OR OWNS �aCL c /`- (-1� eA PERMTr DATE: 5 ,�O 7 COMPLIANCE DATE: A3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � /6, Nn. " Fee T THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplicdtion for �Dioponl *p$tem COIF.5truction Permit Application for a Permit to Construct Repair( j'Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Addres Lot No. n n Owner's Name,Ad apd Tel.No. l 3 8 `• Assessor's Map cel/ e- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 149 4-t .4/ G© 57— 10.9 v r© A✓ Del_ 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 1�/0 S % /a o© Type of S.A.S. Description of Soil L� c, 467 Nature of Repairs or Alterations(Answer when applicable) �GP S �.✓�/��i4 j o 2.S" Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is Board of H _ Signed Date Application Approved by Date Application Disapproved for the following reasons_,.. Permit No Date Issued . . . , ee Fee fT computer:s' }" Ent%red in THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplication for ]Di9;pq,5a1 *p5tem Con!6truction Permit ¢ s / Application for a Permit to Construct Repair( 46pgrade( )Abandon( ) Complete System ❑Individual Components Location Addre kof Lot No. n n Owner's Name,Address and Tel.No. Assessor's Map/Parcel/ / Gb G a T, r E InstalleAr's Name,Address,and Tel.No. Designer's / Designer's Name,4Lddres'ss and Tel.No. S' v Y 7 �� i � G.2 s'• 9 � 33 / 7> 7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building _ No. of Persons Showers( ) Cafeteria( ) Other Fixtures ` {J E ✓ - r Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title i lj 1 Size of Septic Tank 7' 6 Type of S.A.S. Description of Soil 5 Nature of Repairs or Alterations(Answer when applicable) /0 S % ;a Date last inspected: Agreement: 4 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 BB-odrd of Health. Signed %../ - ' / Date f� Application Approved by e7 �/!�� Date ` % Application Disapproved for the following reasons Permit Noc Date Issued 1 P THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( by at l3 "�G �/'s %�� av? r has been constructed'in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�!�'�'"'_ a dated Installer Designer The issuance of this axr4it shall not be construed as a guarantee that the s w 11 function as designed. Date :3 Inspector --j�—-- ---.------------- ------Fee — No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wigool *pgtem construction permit *` , Permission is hereby granted to Construct( )Repair(<)Upgrade( )Abando ( ') System located at2� 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: Construcdo 1st)b Lmpleted within three years of the date of this erm j / Approved b Date:_ ,�� PP Y Town of Barnstable Regulatory Services Thomas F.Geiler,Director �i• s 'riss�Le, • Public Health Division �s Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: M a Z1 Designer: R Mew a ►l° -Installer: Address: . R 0- gox Address: -6 D W r(114 2.S3 7 . //Zy10 On AILG1-1 l°�� was issued a permit to install a (date) (installer) septic system at I (��SZ' Cl�ZG(-t✓ z based on a design drawn by (address) dated a. 2-00 4 ' (designer) 1 I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Re ations. Plan revision or certified as-built by designer to follow. OF Mass o 9 moo`' DARRE E ER N taller's Signature 1 40 olsTEa� \ SgNlTWPa V (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH -THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form TOWN OF.BARNSTABLE , LOCATION 1 ����` s�� SEWAGE #C:9 VILLAGE C 6+0 t+ ASSESSOR'S MAP & LOT . 0 INSTALLER'S NAME&PHONE NO. -7 SEPTIC TANK CAPACrM QUU 4 I �,C41LO LEACHING FACILITY: (type) <<T (size) j x NO.OF BEDROOMS � BUILDER OR OWNS Q t Q-I*yn eAl PERMITDATE: O COMPLIANCE DATE: 3 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 Feet within 300 feet of leaching facility) Furnished by syP✓j TOWN OF BARNSTABLE LOCATION EWAGE # VILLAGE C ASSESSOR'S MAP & LOT "T INSTALLER'S NAME & PHONE NO. TT ��ST• �! SEPTIC TANK CAPACITY LEACHING FACILITY:(type) L (size) L-P 6� NO. OF BEDROOMS � PRIVATE WELL OR PUBLIC WATER 7 k", BUILDER OR OWNER �,e-wa v,)_Ll v C.jZ V DATE PERMIT ISSUED:8 - 3® S DATE . COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ' f ra 20' p Bc- 4g is z c -D� , F 01 f THE COM NWEAL H OF MASSACHUSETTS �- BOAR r - LTH , ... .............OF.. . ............. .............................................................. ip iratiou for Di-wii al Works Tonstrurtinn Vamit (A Ut�". Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal VV System at: C9 f//7 -•-...'.��' ....... ... _lf/lam✓-.. W .. .....--•.........................�---------- --------•----•---------------...............-- i Location_-Ads A V or Lot No. .........- '...... . . ........................................................ Owner Address W � Installer Address Type of Building Size Lot..... `.,t` P._..Sq. feet Dwelling—No. of Bedrooms..._...._..._._. Expansion Attic ( ) Garbage Grinder pa-, Other—Type of Building .... ..�..... No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures -------- ----------.................................. Design Flow................. ............gallons per person per day. Total daily flo ..................................`..._......dons. 04 Septic Tank—Liquid capacity&M_gallons Length____.__------ Width-----:T___.____ Diameter---------------- Dep .............. W Disposal Trench—No. ........... ....... Width.................... Total Length................. Total leaching area--------------------sq. ft. x - Seepage Pit No........ a meter..../........ Depth below inlet...-31.�_........... Total leaching area..j.J.A�. ft. Z Other Distribution box ( ✓f Dosing t nk ( ) Percolation Test Results Performed by...__ __ ._ . .......... Al.�' ---- Date - '��- '5--------------- aTest Pit No. 1----------------minutes per inch e th of Text Pi t_. ._............ Depth to ground water........................ r, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 ............................................................ ........ -------- -------•---•------------------------------------------- -... -... .......... .------ 0 Description of Soil--------------------------------------------------------------------------------------------------------------------------------....................................... x V 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 iITLEE 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 t e board of health. Signed .... - • ----- Application Approved By-- . ....... ...... ......-----••. ........................ ...1&6........-v....k --- Date Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date Permit No. 7� ........ Issued....................................................... Date No— 7 FVie.............. .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD F H LTHT�' ..................OF... . ... ........................... ............................................ . Appliratiou for Bispoiial Works Tongtrurtion Vrrmit Application is hereby made for a Permit to Construct (,1<®r Repair an Individual Sewage Disposal System at: ell',(110-7 .............../......... ........... ..... ......... ....... . ......... ................................ .... .... _ .......................................... or E;No. .......... ...................................................... ................................................................................................. Owner Address ...... ... ......... Installer Address Type of Building Size Lot_._. ----Sq. feet U Dwelling—No. of Bedrooms.__..... Expansion Attic Garbage Grinder ;�f------------------------ Other—Type of Building .......V_A��............ No. of persons.....__..___...._._..__.____ Showers Cafeteria Otherfixtures ....................................................................................................... ......................... Design Flow................ ................gallons per person per day. Total d 'I fl 'T3 ................grallons. aowDiameter--.-_----_---__------------------------------ 1:4 Septic Tank—Liquid 6pacity&VILgallons Length................ Width..__._-____.____e- Depth_.--___-_...__.. Disposal Trench—No. .................... Width_._.._._....._._._.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I/----------- iameter....Z q........ Depth below inlet..... ........... Total leaching area..4_.!.�...��q. ft. z Other Distribution box Dosing tank L Percolation Test Results Performed by.... v' ...... Date_.__ ................ Test Pit No. I................minutes per inch ✓Depth of Tit Pi L .. ............... Depth to ground water...._.____............_. N-4 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ....................................................................... .......".........."------------*-------------------------------------------- 0 Description of Soil........................................................................................................................................................................ ........................................................................................................................................................................................................ -------------------------- ............................................................................................................................................................................. UNature of Repairs or Alterations—Answer when.,applicable.................................................­_........................................... ............................................................................................--------------------------------------------------.............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T ITI I&L 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............%LA...........L-1........"�'V 969f...................................... .......................... ApplicationApproved By--_ ...... ....................... ................... ...... ................. Date Application Disapproved for the following reasons:...............................................I ............................................................... ........................................................................................................................................................................................................ r � Date PermitNo......0.2��-------------------------------------------- IssuedL....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 AL ............... .-A........... 0 FA..I.:.; ................... Tatifiratt of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (.-j'*or"Repaired by.. ................................................................: ............................................................................................................. 7�- Instal ........... at......7...&.... .................. ............................4..!-----------------_--- with--i't The State Sanitary CAe a� degriVed "e has been installed in accordance t e provisions of TI' application for Disposal Works Construction Permit No.--se................................... dated-._.---__-._.--_-_____-_-__--___------.--------. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SY EMI WILL FUNCTION SATISFACTORY. DAT ................ ........il................................. Inspector..._._.. .............................................. THE 11 EM V� AT ........ THE COMMONWEALTH OF MASSACHUSETTS .Ile BOARD OF HEALTH ...................... OF...................................................................................... '? .................. 9�S 74 ..................... N ......................... E�_ %powd Works TV.11mitrurtion "pautit Permission is hereby granted..................................... ........................................................................................................ to Construq or Re air an Individual Sewage . ------- �D ics pa7—&d S t at ......... . - -S- � V - -C-_-, i.... MI, Street -ri as shown on the application for Disposal Works Construction Permit I o.....t.. ......... to------------ ............. ....... .. .......................................................... Board of Health DATE.........................................................................:....... FORM 1255 HOBES & WARREN. INC., PUBLISHERS TOWN OF BARNSTABLE LOCATIO „40"6�, p -SEWAGE # (o VILLAGE ASSESSOR'S MAP LOT f INSTALLER'S NAME & PHONE NO. 77 SEPTIC TANK CAPACITY LEACHING FACILITY:(type)_ (size)L-P NO. OF BEDROOMS_,-3 _PRIVATE WELL OR PUBLIC WATER2/v BUILDER OR OWNER DATE PERMIT ISSUED:A - 313 -- 911 DATE .+COLiPLIANCE ISSUED: VARIANCE GRANTED: Yes — No. oz tz ~aII 1 LZ ` a a �10 z i z z - �b (I oil 0 2i i ' i Y T • • TOP OF FOUNDATION CONCRETE COVER :- CONCRETE COVERS n o 4 CAST IRON 12��MAX. . OR SCHEDULE 40 12"MAX. P.V.C. PIPE 4 SCHEDULE 40 PVC.(ONLY) PITCH 1/4"PER.FT. PIPE - MIN. LEACH PITCH 1/4"PER.FT _ PI T �'0 1 C' INVERT o -' LEA N SEPTIC TANK INVERTS INVERT °a al4 PI DIET. a'- INVERT , EL 36.:. . . . . BOX EL 5.4.� w.. ' : EQ V oa EL.3.7.,•Oi? ,/ . . .. .. GAL. IELw.T INVERT ; �Ww b: :.i: 3/4�# WA Et SY ' -- —W DIA. --� —� o. • o /o DIA. ! PROFILE OF GRouND WATER TAB SEiWAGE' DISPOSALSYSTEM I I J NO SCALE r ®IL LOG _ WI ESSED BY : DATE .7A K. .... TIME(, . . y7`�.� JA/Y s ®°�•Co.:! . . BOARD OF HEALTH � TEST HOL-E 1 TEST HOLE 2 ®�� ENGINEER ELEV.37X.c > . . . ELEV. .. ... . . . . +((, DESIGN DATA . NUMBER OF BEDROOMS 3. TOTAL ESTIMATED FLOW .3 3 D , . GALLONS/DAYU rl ' { BOTTOM LEACHING AREA 17?S/. . . SO.FT. /Pit iI I; t SIDE LEACHING AREA . ./�5� SQ.FT./ PIT i GARBAGE DISPOSAL . . . . .(50% AREA INCREASE) III TOTAL LEACHING AREA . 265. : SQ.FT PERCOLATION RATE MIN/INCH i LEACHING AREA PER PERCOLATION RATE .. . . .. . SQ.FT. '/ NO.. .WATER ENCOUNTERED NUMBER OF LE C LNG PITS t APPROVED . . . . . . . . . . . BOARD OF HEALTH ^S� DATE . . . . . . . I . . . . . .. . . . . . . . . T®T.9L 3�z G�'® AGENT OR tINSPECTOR OF AQ BI —41 . . . . . „:.j Rl lw't i a� 814 PETITION ER P— _ 7 Fern AVE. E.Sandwich, WA '':),37 �„�®'� ATA . �,d• I *AssEssoRs MAP : TEST HOLE LOGS F' Q) PARCEL: ._ _La SOIL EVALUATOR: ! V9, WAVE ` N®TES: FLOOD ZONE _ - �U�1CaA , .' _ -- _ C�Lw� v REFERENCE: DATE 1) The installation shall comply with Title V and Town of Barnstable Board of PERCOLAT ION RAT : Health Regulations. _ 2 2) The installer shall verify the location of utilities, sewer inverts and septic TH- I TH-2 components prior to installation. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. Y 6) Parking shall not be constructed over 1I10 septic components. LOCATION MAP �7 7) The property is bounded by property corners and property lines as depicted. 1 8) The property owner shall review design considerations to approve of total number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the h r $ 1 number of bedrooms. r""" ..3i.... 3.v i(Z�Pi�*'a'. .u'; � r�" t tt�,+; ..,vi�,k-+rs .....:�t•4—.•_- Y , 9) The existing cesspools shall be pumped and backfilled per Title V '' Abandonment Procedures. 1� 10)Proposed leaching is to be within 36 inches of grade or provide venting or cut / --`�- ` - - --- -- as grade permitted by the Board of Health. g 11)System components to be 10 feet from water line. SEPT I C SYSTEM DESIGN ` ?ltr'> �7; FLOW ESTIMATE BEDROOMS AT //0 GAL/DAY/BEDROOM - GAL/DAY ✓- SEPTIC :TANK GAL/DAY x 2 DAYS - GAL �67� l�LLON SEPTIC 3ANIr� - kj'�? USE �� .� �__ _ _ + I SOIL AI,SORf`,ION SYSTEM Ks /r AkA l —� c SIDE AREA.2x ,Z + 1 ots �� ,a�'kor� a ` BOTTOM AREA: ry OIL SEPT I C SYSTEM SECTION T,yvz S. ", , ,. , \ .. 41 in JT1 z, ML.� - 15 . r /�Ol� GAL 1 ' _., i Z1jQv Ww� �'��. SEPT I C TANK 'Volk— SITE AND SEWAGE ©PLAN LOCATION : C�,JWM� PREPARED FOR : l L. SCALE: W DAV I D B . -MASON DATE:�" � o DBC _ENV IRONM �5EN�TAL DESIGNS J EAST SANDWICH . MA W DA E HPALT' A AGENT . ( 5.08 ) 833- 2I77 W I (Y A .AO � V 1 PLAN OF LAND IN COTUIT FOR JOHN SWEENEY ZONE RF TOWN WATER �f C ��yJ�LS �✓ A / AA ✓ of <NM7 f�R �71)ht-5 /' zc11z " /3y Cro'gfz V, S^Irocy 1?ATG/J !ff A'EGoy�WEO /y r7.c00,v V4e� s ti _ A WOOD ST SET r l _ l P`AN p F +rq;, 13235 r _ ..._.. . _- . l Sx� ,� 9.1 ....- y PAUL A. NIERPTHEW �� � No 32G98 aS 31. IL 'TO-6 ci Iva 39 f f t i F 67 116, I QL IL loo � 4V It }o f 0 , "�ac'- -�+--,fir- ._.__. . _ _.. .__ . p'�•' l tll // j 1 h i' ^ S e t 010 Of T RoACD �e° . An, � CH RR,Y TREE RD I �� � � ,� � � � , 2zx�► tv Ar � , A 50 A