HomeMy WebLinkAbout0023 KIMBERLY WAY - Health �3 JKir1p Orly Vl/ay�
Cotuit P
A= 027 070
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TOWN OF BARNSTABLE
LOCATION 3 M SEWAGE# ,2o7j--&47S
VILLAGE C'92kU�l� ASSSESSOR'S MA``P&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Jag
LEACHING FACILITY: (type) 5eQ (size)
NO. OF BEDROOMS 3 / �T
OWNER
PERMIT DATE: / "lLPz COMPLIANCE DATE:T
Separation Distarice 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 �D��e✓, � �l
A �
No. �d �� 0 ! Fee Ion
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYication for Bisposal 6pstrm Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 23 Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel 7 7® J ��
e.
Innnstallle"r's Name,Address,and Tel.No. Desigg-neerrr''ss Name,Address,and Tel.No.
Type of ilding:
Dwelling No.of Bedrooms Lot Size ' sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures _�7
Design Flow(min.required) :� 30 gpd Design flow provided "Z gpd
Plan Date Number of sheets Revision Date
Title j
Size of Septic Tank Type of S.A.S. � .�L� J>C y�&Ve
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ze,4041.1
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 ZHealth.
Signe Z
Date
:2
Application Approved by ✓lnt Date
Application Disapproved by Date
for the following reasons
Permit No. 'D-o(S—-0-7 X Date Issued
-.ew�---
No. 0 � G / Fee f(fin
F THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_�� '' .
E ���
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Bisposar 6pstem Construction Ver,mit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components -
Location Address or Lot No.. 23 � h�� �,/ Owner's Name,Address,and Tel.No. '
Assessor's Map/Parcel 2 7 7V % ,I J /�� � //
o ��'"1]'U'L "6
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
AJA 5�<k S o5- Rq4 2 SOU
Type of ilding: ,+
Dwelling No.of Bedrooms .3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3o gpd Design flow provided S p2, gpd
Plan Date Number of sheets Revision Date
i
Title
i �`"Size of Septic Tank (.! Type of S.A.S. D25/&ye,//
Description of Soil, s
Nature of Repairs or Alterations(Answer when applicable) Z ear / !O r
"•"^� /
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 DateC�
Application Approved by v f Date r S�
Application Disapproved by Date
for the following reasons xa if
Permit No. 'D o(;" 0 7 Date Issued 7 �b
f
------------------------------------------------------------------------------------------------------------------- ---------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-siteewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by
f at ,G2 4 w•g- has been constructed in accordance
with the provisions of Title 5 an he for DisposalISystem Construction Permit No. o f j Q 7 Ydated
Installer RLV0&w hs j eA �`_ Designer_ -- �S4&y
#bedrooms {i�� Approved design gpd
The issuance of this jpei mit shall note construed as a guarantee that the system wi.fim_t'i/oh as desi
Date
Inspector
No. U7 Fee Uy_
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Bisposal s*pstetu .4 tructlon permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at 2 3 Kk-k 6-
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 perm't
Date L.(- - /j Approved by C/)�i. S
Town of Barnstable
Regulatory Services
Thomas F. Geller,Director
UABIL Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: Sewage Permit#201�5'--'�' 5 Assessor's Map/Parcel �1- 70
Installer&Designer Certification Form
Designer: �UW AY—.P� Installer: UD�✓�Y /��/b i�'
Address: w gC1 /7Z:2 Address,: 44'�) /Yid
On l�-�- /S� �a�I� S �V was issued a permit to install a
(date) (' taller)
y`
septic system at 23,�r ,� �yh/ �iT based on a design drawn by
(address)
411 E yW datedZ-
L��d"esigner) �
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. Stripout (if required) was inspected and the soils
were found satisfactory.
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 Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if requir da..vK spected'and the soils
were fo satisfactory.' w
DAVID
D.
FLAHERIY,3R, N
(Iligtalle s S tore) No. 1211
71,� P, SgNITAR%
(Designer's Signa A, (A Designers 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:\office fomtsdmignercertification form.doc
- P
TOWN OF BARNSTABLE
s� CL
LOCATION A 3 h-11m e rlrt l r Lv� `, SEWAGE #
VILI:AGE 0-oT, % ASSESSOR'S MAP & LOT AfI
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY ✓��"PL�e� / �dX
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS .3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 071 6 j�' ��/�✓�'�
DATE PERMIT ISSUED: - 'd
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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TOWN OF BARNSTABLE ✓
LOCATION' �.1� �rn �_` y Q_V SEWAGE #
VILLA- =E ASSESSOR'S MAP&LOT
INSTALLEWS NAME&PHONE NO_
SEPTIC TANK CAPACITY n
LEACfUNG FACILITY:(tw) 1'��"f' (size) ' /6M yrq
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the,Bottom of Leaching Facility Peet
Private Water Supply Well and Leaching Facility (if any wells exist
on site or within M feet of leaching facility) Fit
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet f leach in efacili ) Feet
Furnished by h
a
i
i
o e
LoiD
Alp-- yl a -F_ 411 ,
ar '
T4DWNi OF:BARISTA13
SCWACJB
LOCAa'I'ION. t
VII i ABC c Q J A�S�SSOWS M"& S:OT___�—___
]AT9T13 ii'S N ArJI PHONE Y+it3
F'1"LC 'X'pl`TTc�OAIa CI't"x _.J_'_�.._._
Supurataur� t E Ace I#cwv.eep Old".
11 axlmum laci}usr d GtAutAdw stet'!'al�le to the l3nuarr�of Duo Lng l-7tir;ility
l�alvd(ett�iupl+lylcafd t,���.6tiip�1�acltry pC Hazy delis cxis ?rs rye
att a to ac vvlt��n 2OR£eat of lea hwd fitcIlity) —�- -�.:----�--�-
psi i4 yf Wetland - 'd.I.cachi tt call@y(1<E uny w�tl nd5 exasc
tv}tl�tsa 3Q0;fcsd of logos Ing
a
A -�✓- VP �- i'
TOWN OF BARNSTABLE
LOCATION 423 LZMSt"11' SEWAGE #
VILLAGE C ASSESSOR'S MAP& LOT a
D/,5,a c7:,es Q
IES NAME&PHONE NO. 0 �/I�Co 1? •o�
SEPTIC TANK CAPACITY .S£'A/! i.� j�f'c-71-, �-
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER R•OWNER
I`+ PERMITDA`I : : 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
' r
O x�
AAo.
3�r
off°
r
Town. of Barnstable P#
yI� Departinent of Regulatory Services
>+AxrtarAer� Public Health Division Date
MASS.
�A a639• 200 Main Street,Hyannis MA 02601 ,
V I �j
7L
Date Scheduled {� V, .1 t t i ld d M
Time Fee Pd, d 2-
So " Suitabiti Assessment or Se is
Performed By:.. Witnessed By:
LOCATION& GENERAL INFORMATION
Location Address Z,3 IA , Owner's Name CIsq
G�t/tr9- r'1 Address
5►�'''wf-
Assessor's Map/Parcel: ?,�}/ e7 Engineer's Name o k4v frie-/// , . L ,
NEW CONSTRUCTION. REPAIR Telephone#
Land Use 12,04
Slopes(%) L Surface Stones 14
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well _-/�/t� . ft
Drainage Way �ex ft .Property Line 3o ft Other
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
-/tom:1 t f-•z
c, - -- — -
s�
® fTl
-
.
Parent material(geologic)fzr&C
Depth td Bedrock
`r Depth to Groundwater. Standing Water in Hole: Weeping from Pit pppe
Estimated Seasonal High Groundwater
DETERNITNATION FOR SEASONAL HIGH WATER
Method Used:.
Depth'Observed standing in obs.hole: in, Depth to soli mottles.
ht,
Depth to weeping from side of obs.hole: In. Groundwater AdjuAlment {r•
Index Well#_llf!!:� Reading Datc:- / Index Well le�ol � gr�,tiiCtor, _ A,�.Groundwater Level
PERCOLATION USA' ;bntp xhna 11 00; "
Observation /
Hole#
� � Time ath"
Depth of Pert Time at 6" N 1'
Start Pre-soak Time @
— Time(V-G") Ye
End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) -/v y
Original: Public Health Division Observation Hole Data To Be Completed on Back---------- +
�t •
***If percolation test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:1S EPTIC\PERCFORM.DOC
DEEP.OBSERVATION MOLE LOG Hole#
! Depth from Soil Horizon Soil Texture Sdii Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders.
onsistency.%gravel)
313 �.1 �-
3 � s r 6 4a
C'S s
DEEP OBSERVATION HOLE LOG Dole#.j:LZ
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
o sistency,%Graven
�6 C7 fU� R 3 .
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistencv.%Oravch
i f I
DEEP OBSERVATION HOLE LOG Bole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling '(Structure,Stones;Boulders.
Consistency.
y
IF,lood Insurance Rate Map:
Above 500 year flood boundary No A, Yes
Within 500 year boundary No J Yes�1
Within 100 year flood boundary No. Yes ,
ti
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious m M erial exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring peeous aterial?
Certification
I certify that on �� Z .0 (date)I have passed the soil evaluator examination approved by the
Department of Envi onm tal Protection and that the above analysis was performed by me consistent with .
the required trainin ,:expertise and experience described in�10 CMR 15.017.
Signature Date 2
Q:\SEPT1C\PERCP0RM.D0C
cc •
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mom- ,
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CO Postage $
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Certified Fee a � Z
O # Postmark
O Return Receipt Fee Here C7�
p (Endorsement Required)
Restricted Delivery Fee �Q9 L o dv�
O (Endorsement Required)
p Total Postage&Fees $
P�
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o Charles E. Colella
1171- 23 Kimberly Way
Cotuit, MA 02635
Certified Mail Provides:
a A mailing receipt
o A unique identifier for your mailpiece
a A record of delivery kept by the Postal Service for two years
Important Reminders.
a Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
o Certified Mail is not available for any class of international mail:
a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
a For an additional fee„a.Return Receipt may be requested to provide proof of
delivery.To obtain Return;Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
e For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted-Delivery".• pp
cle at the post ostmark n the off office for postmarking.l
pIf is desired,
post arklonsthe Certified esent the Mrti-
ail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry. j
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 j
I
UNITED STATE D6 SERVICE First-Class Mail
>w'� Postage&Fees Paid
Permit No.G-10
• Sender: Please print your name, address, and ZI1+4 in this box •
I
I
Town of Barnstable
I Public Health Division
200 Main Street .
Hyannis, MA b0' '�' °L (lug
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H!il! t1 tit trit!!i l'!1-tt�t it,1
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MOMME
® Complete items 1,2,and 3.Also complete A. Sig
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item 4 if Restricted Delivery is desired. _ �; ; Agent
® Print your name and address on the reverse X L ❑Addressee
so that we can return the card to'you: B. Received b (Print d Name) C. Date,of liv ry.
is Attach this card to the back of the mailpiece, 1
or on the front if space permits. ��' 4�
D. Is deliveryaddress different from item 1. ❑,.es
1,, Article Addressed to:
If YES,enter delivery address below; o
I �
I I
Charles E. Colella
23 Kimberly Way
1, GOtU1t, MA 02635 3, Service Type
❑Certified Mail ❑Express Mail
__ _ ----- ❑Registered ❑Return Receipt:forMerchandise
O Insured Mail ❑C.O.D:
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number E,
(Transfer from service label) I ; .7 012 1010 000,0 2851 ,39148 v 1
PS Form 3811. February 2004 Domestic Return Receipt +02595-02-M-1540
Town of Barnstable Barnstable
. Regulatory Services Department f
W.RMMABM
� ' Public Health Division
200 Main Street,Hyannis MA 02601 2007
Office: 508-8624644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 .1010 0000 2851 3948
November 12, 2014 `
Charles E Colella
23 Kimberly Way
Cotuit, MA 02635
ORDER TO COMPLY WITH STATE ENVIRONMENTAL.CODE, TITLE 5
The septic system located at 23 Kimberly Way, Cotuit,MA was last inspected on
10/27/2014,by Sean Mcelroy, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of.sewage.into facility or system component due to overloaded or.
clogged SAS.
• Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future.
enforcement action.-
PER ORDER OF THE BOARD OF HEALTH
U
Tho c e�R.S. CHO
Agent of the Board of Health .
•
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\23 Kimberly Way cot Nov 2014.doc
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y Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is Cotuit ' ' MA;. 02635 10-27-14
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address ,
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification „
I certify that I have.personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
S I
❑ Needs Further Evaluation by the Local Approving Authority
10-27-14
Ins ector's Signature \ Date r
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the .
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. q
t5ins•3/13 Title 5 Official Inspection tF.rm . urface Sewage Disposal System•Page 1 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is Cotuit MA 02635 10-27-14
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310'CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
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", "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):
t5ins•3t13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is required for every Cotuit MA 02635 10-27-14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.): r .
❑ 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):
4
❑ 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) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title.5 Official Inspection Form*Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is required for every Cotuit MA 02635 10-27-14
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) 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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility.or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°M 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is it t MA ou r 02635 . 10-27-14
required for every C �
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 theSAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
'of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is.a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd. .
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D. -
Yes No
❑ ❑ the system is within 400 feet•of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to'a surface drinking water supply
EJ the.system is'located in a nitrogen sensitive area (Interim Wellhead Protection
El the
=IWPA) or a.mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�M s 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is required for every Cotuit MA 02635 10-27-14
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?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Syey`or 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is required for every Cotuit j MA 02635 10-27-14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® •No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump PUMP- ❑ Yes ® No
Last date of occupancy-, 7 10-2014
- Date
Commercial/Industrial Flow Conditions: '
Type of Establishment:
Design flow(based on 310 CMR,15.203):
`Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?. ❑ Yes ❑ No
Industrial waste holding tank'present?v ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is required for every Cotuit MA 02635 10-27-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner--pumped 4yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
I
9 P
❑ 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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is required for every Cotuit MA 02635 10-27-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
Approximate age of all components, date installed (if known) and source of information:
1984
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth 24"below grade: 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.):
Good condition.
Septic Tank (locate on site plan):
Depth below grade:
18"
feet
Material of construction: '
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metali list age: years
Is age confirmed by a Certifcate.of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: s 1000 gal
Sludge depth:
12"
Tins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' M 23 KimberlyWay
Y
Property Address
Mary Colella
Owner Owner's Name
information is required for every Cotuit MA 02635 10-27-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 Kimberly Way
Property Address_
Mary Colella
4 Owner Owner's Name -
II information is required for every. Cotuit MA 02635 10-27-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: w '
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
_ gallons-per day �
Alarm present: ❑ Yes ❑ No
Alarm level: _ Alarm in working order: tir, ❑ Yes ❑ No
r °
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Forrn:Subsurface Sewage Disposal System•Page 11 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is required for every Cotuit MA 02635 10-27-14
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.):
Good condition.
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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
r Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name .
information is required for every Cotuit MA 02635 10-27-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑. leaching trenches number, length:
❑ , leaching fields number, dimensions:
❑ overflow cesspool. number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit had water level at 12" below inlet invert with stain lines at and above inlet invert.
a
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
4
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is required for every Cotuit MA 02635 10-27-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
✓ Commonwealth of Massachusetts
W Title 5 Official Inspection Form
'g Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is Cotuit MA 02635 10-27-14
required for every '
page. CitylTown 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 separatelyAxe-- -- -------
"
it
1
16? 30
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is Cotuit MA 02635 10-27-14
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
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:
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 23 Kimberly Way
Property Address
Mary Colella
Owner Owner's Name
information is Cotuit MA 02635 10-27-14
required for every ,
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
p
tSins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
VV
23 Kimberly Way
Property Address .
Bank Owned (contact David Holt @ Today Real Estate 800-966-2448) -
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09'
•
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector '
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State- Zip Code
508-495-0905 S13971
Telephone Number License Number ,
B. Certification
I certify that I have personally inspected the sewage disposal system at this add and tM the> a.
information reported below is true, accurate and complete as of the time of the it ction. T-be ins-ection
was performed based on my training and experience in the proper function and ma ntenanrof o 'site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to ection5.34of .
Title 5 (310 CMR 15.000).The system:
ri
[A Passes El Conditionally Passes ❑ Fai r
❑ Needs Further Evalu on by the Local Approving.Authority
.o
Inspector's Signature Date
The system inspector shall.submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,•the inspector and the system owner shall submit the •
report to:.the appropriate regional office of the DEP.The original should be sent to the system:owner
and copies sent to the buyer, if applicable, and,the approving authority. ^:
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�D
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
�M 23 Kimberly Way
Property Address
Bank Owned (contact David Holt @ Today Real Estate 800-966-2448)
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure. Recommend pumping now and every two
years for maintenance and to prolong life of system.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
.Answer es, no or not determined Y N ND in the for the following statements. If"not
Y ( ) ❑ 9
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments
4.
,M 23 Kimberly Way +
Property Address Y.
Bank Owned (contactDavid Holt@'Today Real Estate 800=966-2448) w
Owner Owner's Name
information is required for Cotuit'= MA 02636 6-21-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): ,
❑ ' distribution boz is leveled or replaced
ND Explain:
1
El
1 �
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 r
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health: .
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety,or the environment,-
1. System will pass unless Board of.Health determines in accordance with 310 CMR
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
El Cesspool or privy is within 50 feet of a bordering vegetated wetland ova salt marsh
2.'System will fail unless the Board of Health (and Public Water Supplier, Warily)
determines that the system-is functioning in a manner that protects the public health,
safety and.environment.
4h
❑ The system has aseptic tank and loll 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. ,
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 Kimberly Way
Property Address
Bank Owned (contact David Holt @ Today Real Estate 800-966-2448)
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and-SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool Y
Liquid depth in cesspool is less than 6° below invert or available volume is less
El ®
" than '/ day flow
El ® 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.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
,M 23 Kimberly Way -
Property Address
Bank Owned (contact David Holt@ Today;Real,Estate 800-966-2448)
Owner Owner's Name - >
information is Cotuit, MA 02636 6-21-09
required for `
every page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
D) -System Failure Criteria Applicable to All Systems (cont.):
�,.. Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within-50.feet of a private water supply well.
❑ E 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
u 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.]
❑ IDThe system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303',therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes .No ,
❑ ' ❑ ' the system,is within 400 feet of a surface drinking water supply
❑ the system is within•200 feet of,a tributary to a;surface drinking water supply.,
El the system is located in:a nitrogen sensitive area (Interim"Wellhead Protection
Area 7 IWPA)or a mapped Zone II of a public water supply well
' If you have answered"yes'''.to`any question it Section E the systemis 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.
t5insp official document-03/08 A Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 23 Kimberly Way
Property Address
Bank Owned (contact David Holt @ Today Real Estate 800-966-2448)
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No '
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System.Form Not for Voluntary Assessments
,M 23 Kimberly Way
Property Address
Bank Owned (contact David Holt @ Today Real Estate 800-966-2448) -
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09
every page. City/Town ;. ; . State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions: ,
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder? , , ❑ Yes ® No
Is laundry on a separate sewage system? [if yes*separate inspection required] ❑ Yes 0 No
" Laundry system inspected? El Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if,available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 4-09
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
• a. . ._ •. ... .... .. a..,r. ,. 1•,s. :i` ,.1
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.; etc.):
Grease trap present? r{, ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary-waste discharged to the Title 5 system? ❑ Yes ❑ No
i Water meter readings,if available:, • ..,
Last date of occupancy/use: Date
Other(describe):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 Kimberly Way
Property Address
Bank Owned (contact David Holt @ Today Real Estate 800-966-2448)
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) 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:
1984
Were sewagez odors detected when arriving at the site? ❑ Yes ® No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,i, ,
23 Kimberly Way w-:
Property Address
Bank Owned (contact David Holt @ Today Real.Estate 800-966-2448),
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09 +
"
every page. City/Town s State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 22"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.):, t ;
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 16"feei:
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: 1000gal
Sludge depth:
12"
Distance from.top of sludge to bottom of outlet tee.or baffle . 20
Scum thickness x;, W r ,,
Distance;from top of scum to top of outlet tee or baffle 5
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined?
Tape
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 Kimberly Way
M
Property Address
Bank Owned (contact David Holt @ Today Real Estate.800-966-2448)
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene' ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction: '
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments)' '
wM 23 Kimberly Way
Property Address
Bank Owned (contact David Holt @ Today Real Estate 800-966-2448)
Owner Owner's Name ,
information is required for Cotuit MA 02636 6-21-09
every page. City/Town State Zip Code Date of Inspection ,
D. System Information (cont.)
Tight or Holding Tank(cont.) *.
Dimensions:
Capacity:
gallons
Design Flow:
g gallons per day ,.
Alarm present: . ❑:,Yes t ❑ No
Alarm level: Alarm in working order: „❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
, h
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.): -
R
Good condition.
Pump Chamber(locate,on site plan):'
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes` ❑ No
t5insp official document-03108 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official , Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
23 Kimberly Way
Property Address
Bank Owned (contact David Holt@ Today Real Estate'800-966-2448)
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type
® leaching pits number:
1-1000ga1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was empty at inspection with stain line at 18"below inlet invert.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form=Not,for Voluntary.Assessments
s-
�M 23 Kimberly Way .;.'
Property Address h ,
Bank Owned (contact David Holt @ Today Real Estate 800-966-2448),,, r
Owner Owner's Name f,
information is required for Cotuit MA 02636 6-21-09;,r
every page. City/Town y State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools(cesspool must be pumped as part of inspection)(locaWon site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
L•v
Depth of scum layer,
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes, ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding,.condition of vegetation,
etc.):
Privy(locate on site plan): ,
1.
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp official document•03/08 Title 5'Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
p - . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 23 Kimberly Way
Property Address
Bank Owned (contact David'Holt @ Today Real Estate 860-966-2448)
Owner Owner's Name
information is required for Cotuit MA 02636 6-21-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
.to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
A 9aek
�
A-P-ai
�r �I
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage..Disposal System Form Not for Voluntary Assessments.-,,,, 4
23 Kimberly Way _r ;
Property Address
Bank Owned (contact David-Holt @ Today Real Estate 800-966-2448)-
Owner Owner's Name
information is Cotuit MA 02636 6-21-09
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
El Check Slope
❑ Surface water .
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20'
feet
„Please,indicate all methods used'to determine the high ground water elevation:
A _r
�, `_` ❑_ 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 groundwater elevation: '
USGS maps show groundwater at greater than 20'.
r '
t5insp official document•03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
L.
Health Complaints
27-Mar-03
Time: 2:15:00 PM Date: 3/26/2003 Complaint Number: 3966
Referred To: DAVID STANTON Taken By: DENISE PERRY
Complaint Type: GENERAL
Article X Detail: ILLEGAL OPERATIONS
Business Name:
Number: Street:
Village: COTUIT Assessors Map-Parcel:
Complaint Description: COMPLAINANT HAS FOUND HORSE HOOF
PRINTS AND HORSE DROPPINGS (9 BIG
TREASURES) IN BACK AND SIDE OF HER
YARD. IS NOT SURE WHERE THE HORSE IS
COMING FROM BUT STATES THERE ARE
MANY STABLES IN THE AREA.
Actions Taken/Results: DS & DD WENT TO SAID LOCATION.
THERE WAS A LOT OF HORSE PRINTS IN
THE YARD, AND SEVERAL PILES OF
HORSE MANURE. NONE OF THE
NEIGHBORS YARDS APPEARED TO BE
AFFECTED BY IT. LOCATION OF HORSE IS
UNKNOWN, BUT THERE IS DEFINITE
EVIDENCE OF A HORSE BEING ON THE
SAID PROPERTY. HEALTH DEPARTMENT
CANNOT DO ANYTHING, AS NO HORSE
WAS SEEN LOOSE AT THE PROPERTY. DS
CALLED COMPLAINANT, AND LET THEM
KNOW THEY MAY WANT TO CONTACT
POLICE DEPARTMENT IN THIS CASE.
Investigation Date: 3/26/2003 Investigation Time: 3:15:00 PM
1
� COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r
DEPARTMENT OF ENVIRONMENTAL PROTECT
RECEIVED
I y
V. I
350 MAIN STREET MAR 21 2002
WEST YARMOUTH,MA
508-775-2800 TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 27 PAR 70 PARCEL
Property Address: 23 KIMBERLY WAY LOT --
COTUIT,MA 02635
Owner's Name: DONNA MONTY
Owner's Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Date of Inspection MARCH 11,2002
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection. The inspection was
performed based on my training and experience in the proper function and maintenance of on site sewage
disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310
CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
47
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of
Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a
design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the
appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot
he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at
that time. This inspection does not address how the system will perform in the future under the same
or different conditions of use.
Title 5 Inspection_Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM-
PART A
CERTIFICATION(continued)
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY,DONNA
Date of Inspection: MARCH 11,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
_ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY,DONNA
Date of Inspection: MARCH 11,2002
C. Further Evaluation is Required by the Board of Health: N/A
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 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 salt marsh
t,
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY,DONNA
Date of Inspection: MARCH 11,2002
a •
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool 00 fT—
X Liquid depth in oesspeel is less than 6"below invert or available volume is less than''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is 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 15.364. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY,DONNA
Date of Inspection: MARCH 11,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X 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
X Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health. .
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY,DONNA
Date of Inspection: MARCH 11,2002
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage 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 2 years usage(gpd)): 2000 35,000/2001 29,000
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1984 PERMIT#84-634,NEW DISTRIBUTION BOX
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY,DONNA
Date of Inspection: MARCH 11,2002
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 20"
Material of construction: X concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28" '
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 AND TAPE
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.OUTLET BAFFLE,TANK AND COVERS 20"BELOW GRADE.NO SIGN OF
OVERLOADING SEEN IN TANK.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY,DONNA
Date of Inspection: MARCH 11,2002
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
DISTRIBUTION BOX IS NEW, 16"X16",28"BELOW GRADE WITH COVER AT 16". ON LINE IN,ONE
LINE OUT.BOX IS CLEAN,SOLID AND LEVEL.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY,DONNA
Date of Inspection: MARCH 11,2002
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 1,000 GALLON PRE CAST PIT WITH COVER 32"BELOW GRADE.30"WATER IN
PIT.STAIN LINE AT 36",NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
CESSPOOLS: N/A (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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
L '
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY,DONNA
Date of Inspection: MARCY 11,2002
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
o
. /
o
Title 5 Inspection Form 6/15/2000 10
Page I 1 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 KIMBERLY WAY
COTUIT,MA 02635
Owner: MONTY, DONNA
Date of Inspection: MARCH 11,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 53.3 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA
WELL SDW 253 53.3'
ZONE C 10'
ADJUSTED 43.5'
V_5 s
.s33 i
Title 5 Inspection Form 6/15/2000 11
�u U 2-�a$ Fee �VV//
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: LO
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for ;Di6pont *p!tem Construction 3dermit
Application for a Permit to Construct( )Repair( /yfpgrade( )Abandon( ) ❑Complete System A51 vidual Components
Location Address or Lot No. Ij £/?,/-% " Owner's Name,Address and Tel.No.�
Co 7_.rT ^a u-rK �a.v
Assessor's Map/Parcel c7 2 _2 d e/,,# Ca u,T
Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No.
GD
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)1'4� C
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss d by this Board of Healt .
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No.,p 60 .U Date Issued
Q 2 Fee /
` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC,HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppliCation for ;Dizpozal *pgtem Conelruction permit
Application for a Permit to Construct( )Repair( `4pgrade( )Abandon( ) ❑Complete System A6vidual Components
Location Addressor Lot No. 3 ,Ar/m,8 Ir IP,4,K A-4 Owner's Name,Address and Tel.No. .i �'' y�U-(�,/07
Assessor's Map/Parcel
i7-
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
/�/e J-vp-1!9S -p�./'ate
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 �r:
Size of Septic Tank Type of S.A.S.
Description of Soil j
r^� I
Nature of Repairs or Alterations(Answer when applicable), �► r /,a C. F
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 plac,eijhe system in operation until a Certifi-
cate of Compliance has been iss d by this Board of Healt .
Signed Date 3" 0,2
Application Approved by Waif Date <)
Application Disapproved for the ollowing reasons
Permit No. �,Uu p —Q 9-r Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ).Repaired ( 4-r6pgraded( )
Abandoned( )by f ( ,,4/t/C 0 !3 4/ :2 7- 4g,
at °J Jot- 1 14.1 .4 1'/10 4✓ it'14 T has been constructed in accordance
with the pr isions of Title 5 and the for Disposal System Construction Permit No. �t�u�-�K dated .3-�l'--(��-
Installer Designer r
3i
The iss ce of this permit shall not be construed as a guarantee that the syst ill`f 'nction as des d.
Date � ^ V n Inspector Ml�
No. 7rZ(\ .f)� Fee
a-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi!�Poga[ *pgtem Construction Permit
Permission is hereby granted to Construct(. )Repair( &�rUpgrade( )Abandon� )
System located at A 3� r-//Yl S � y' lv/1 7--
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 per tt.
Date:�Z �) Approved by 1/�/
TOWN OF BARNSTABLEv.
LOCATION A 3 LM4 6
lr f..,o�j SEWAGE #
VILLAGE "•OoTL,i T ASSESSOR'S MAP 6z LOT A
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
.SEPTIC TANK CAPACITY
LEACHING FACILITYAtype) (size)
NO. OF BEDROOMS 3PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: 3- 0
' '
DATE COMPLIANCE ISSUED: f-
VARIANCE GRANTED: Yes No
- I
,g•
�i" Al
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617•292
1AILLI.A,NI F NELD rd(tn
Go%cmor _
ARGEO PALL CELLUCCI loy 6 1 D��'
Lt Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INS IONF, 4f 1q 99 C'T� s
PART A lTy FpllgB�
CERTIFICATION
Property Addres�s:3 Kimberly Way ,IaErsjo�nsi S Address of Owner. C
Date of Inspection: 9/30/97 (If different) g
Name of Inspector: JoseAh P.Macomber Jr..
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J•P•Macomber & Son Inc.
Mailing Address: BOX 66 Centerville,Mass . 02632
Telephone Number: -508-775-1118
CERTIFICATION STATEMENT
I cert,ly that I have personally inspected the sewage disposal system at this address and that the information reponec :relow •s vu a:c
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper Ivn•-•c� ar
maintenance of on-site sewage disposal systems. The system
Passes II
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Dale:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of compJelins ir',
inspecion If the system is a shared system or has a design flow of 10,000 gpd or greater, the Inspector and the system ovvT-ef sr.31! s-,D,
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to T,e svuem o-
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D.
AI SYSTEM PASSES:
have not found any information which indicates that the system violates any of the failure criteria as deiineC ir. 31•0 C.�.�: 3:
Any failure criteria not evaluated are indicated below.
COMMENTS:
BJ SYSTEM CONDITIONALLY PASSES:
Vd One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. Tne sss:er-
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 --), -o!
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cen, scale
Compliance (anached) indicating that the tank was installed within twenty (10) years prior to the date of tr•e m mac, or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or ex-fdtratiOr o- ca
failure is imminent. The, system will pass inspenion if the existing septic tank is replacec with a conform,ng set < -j-.
as approved by the Board of Health.
Ir•v>,••d 0�/25/5�1 s'•p• 1 of 10
DEP on the Wond Woe weo nnp:awww magnet state ma uvoep
Printed on RecyUeO Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properly Address: 23 Kimberly Way Marstons Mills,Mass .
o,.ner: Craigville Realty
Date of Inspection: 9/30/97
e) SYSTEM CONDITIONALLY PASSES (continued)
�Q Sewage backup or breakout or high static water level observed in the distribution box is Cue (G oro',e--- 0' G
Pipets) or due to a broken, settled or uneven distribution box. The system will pass inspect,on it
Board of Heal(h). Describe observations:
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) Tne sys:ern ass
inspection if (with approval of the Board of Health)
broken pipets) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
AILQ Conditions exist which require funher evaluation by the Board of Health in order to determine if the system is fa,l n3 ;c p o;e . :'e
public health, safety and the environment
U SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONIvC IN A
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
V—v 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
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE( DiTER�slNES Tr++'
THE SYSTEM 15 FUNCTIONINC 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 :s within 100 feet to a s.;race -.!e
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public v a:er suaal. e,
4e The system has a septic tank and soil absorption system and the SAS is within 50 feet of a pr,va:e -ate! s.,oc -el.
jW The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feel or -sore
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compo.;nes
the well is Iree from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is ec_a �
less than 5 ppm. method used to determine distance (approximation not valid)
3) �OTHER
I
tr•�1••C 0�/7s/f7) ➢•q• 2 of 10 ,,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.`,s
PART A
CERTIFICATION (continued)
Property Address: 23 Kimberley Way Marstons Mills Ma
O-ner: Craigville Realty
Date of Inspection: 9/30/97
DJ SYSTEM FAILS:
You must indicate e-. et "Yes or "No" as to each of the following
1 have determined that the system violates one or more of the following failure criteria as definec in 310 C,-.-. t j
for this determination is identified below. The Board of Health should be contacted to determine what well be necess,i,% :o
the failure
Yes No,
L/ Backup of sewage into facil�rY or system component due to an overloaded or clogged SAS or cess000
Discharge or ponding of effluent to the surface of the ground or surface waters due to an o erloae e or c og3�
cesspool.
/IJpy� Staiic liquid level in the clistribution boa above outlet invert due to an overloaded or clogged SAS o
ou d depth n g*+4oQe4 is less than 6" below invert or available volume is less than 1.'2 ca:
Required pumping more than a times in the last year NOT due to clogged or obstrucled
~'umber of times pumped —
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwa,er ele�a:ic^
Any ponion of a cesspool or privy is within 100 feet of a surface water supply or tributar`: :o a s ^ace a er s_r�
Any portion of a cesspool or privy is within a Zone I of a public well.
Any ponion 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 paler
acceptable water quality analysis If the well has been analyzed to be acceptable, anach coon of well
coliform bacteria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen
EJ LARGE SYSTEM FAILS:
7ou must indicaie 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 faciliry with a design flow of 10,000 gpd or greater (Large System) and the system �s a s•x c
public health and safety and the environment because one or more of the following conditions exist
yPs h'O_
/S�[�L[rj the system is within 400 feet of a surface drinking water supply
AnA 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 rrapo.rs Zone e a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundha:er Irea? s
requirements of )1 a CMR 5.00 and 6.00 Please consult the local regional office of the Department for funher niormat,c^
r•� ••G 0�/)5/9)1 v•y• 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Properly Address: 23 Kimberly Way Marstons Mills Ma
Owner: Craigville Realty
Date of Inspection: 9/30/97
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following
Ye NT
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 rece,�,ng normal
now rates during that period. Large volumes of water have not been introduced into the system rece.n:
as pan of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
— The facilrtY or dwelling was inspected for signs of sewage back-up.
The system does not receive non sanitary or industrial waste flow
2Z — The site was inspected for signs of breakout.
— `��
All system components, e+kludtng 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 rnspecied for cond,,,on o
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
—
The faciliry owner (and occupants, if different from owner) were provided with information on the aroDer maintenance
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
— Determined in (he field (if any of the failure criteria related to Pan C is at issue, approximation of distance s
unacceptable) (15.302(3)(b))
(r.vI..d D.9. 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properly Address:23 Kimberly Way Marstons Mills Ma
Owner: Craigville Realty
Date of Inspection: 9/30/97
FLOW CONDITIONS
RESIDENTIAL:
Design now. A p.d./bedroom for S.A.S.
Number of bedrooms:,
Number of current residen(s",�
Garbage grinder (yes or no):.z2b
Laundry connected to system (yes-or no):Yve'
Seasonal use (yes or no)1126—) ,
seater meter readings, if available tlast two (2) year usage (gpd):
Sump Pump (yes or no):A&)
Last date of occupancy'
COMMERCIAUINDUSTRIAL:
Type of establishm nc
Design flow: gal(ons/day
Grease trap present. tyes or no)A224
industrial Waste Holding Tank present: (yes or no)Zff
Non-sanitary waste discharged to the Title S system: (yes or noA)A
Vvater meter readings, if able. VA?
Last date of occupancy.
OTHER: (Describe) Alh
Last date of occupancy lyk
GENERAL INFORMATION
PUMPING RECORDS d ou ce ���formation
i�v71rTl•�r��,
System pumped as pan of inspection: (yes or no)"
If yes, volume pumped _gallons
Reason for pumping AM
TYPE O SYSTEM
Septic tank/6+ S+e+s— Vsoil absorption system
__A& Single cesspool
4V Overflow cesspool
,4/d Privy
_1k Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA ATe/chnology etc. Copy of up to date contractl
Other /7J
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
D&y• 5 of 10
SUBSURFACE SEtVACE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 23 Kimberly Way Marstons Mills Ma
0-net: Craigville Realty
Date of Inspection: 9/30/97
BUIIDINC SEWER:
.ocate on site plan)
Depth belo, grade
Material of cons( uctron ca I iron aO VC offer (explain)
Distance irom private water supply well or suction line /Y,
/
Diameter
Comm nts: (condition of lomts, venun , evidence f leakage, etc)
S ' —
,4l �
SEPTIC TANK: ��'l� d�s
.�oc.a:e on site plan)
Ifl
Depth below grade
.vsaienal of constrvclron. Y concrete _metal _Fiberglass _Polyethylene _other(expla,n)
it lank is metal, list age Is age confirmed by Certificate of Compliance /U (Yes/No)
D.mens.ons .?r A"
-/��/w1��
Sludge depth y�,�;
Distance from top of sludge to bonom of outlet tee or baffllee/?71�
Scum thickness L '/
Dolance irom top of scum to top of outlet tee or baffle
D.stance from bonom of scum to bonom of outlet tee or baffle /Z/-
-+ow d,mens,ons were determined./XPr2`�'/./l/`P�_.
Comments
trecommendal'on for pumping, Condit, of inlet and outlet tees or baffles, depth of liquid level in rel ljon to outlet nveri, s!r.:^_:3
ntegrrtY, evidence of leakage, etc.) Qy �� r y''Ol�IT =%
CREASE TRAF`df�e
notate on site plan)
Depth below grade
natenal of conslrv� oTt,,L4concrete,�L etal�(/�fiberglass�Polyethylene,(go(her(explain)
Drmens;orw
Scum thickness. VIly
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of sc m to bonom of outlet tee or baffler
Dale of last pumping
Comments
trecommendatron for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet rover.. slr:(.t: 3.
,ntegnry, evidence of leakage, etc.)
it-1—d 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 23 Kimberly Way Marstons mills Ma
Owner: Craigville Realty
Date of Inspection: 9/30/97
TIGHT OR HOLDING TANK:kjy (Tank must be pumped prior to, or at time, of inspection)
(loc.ate on site plan)
Depth below grader
Malenal of con strucijonx,Aconcrete vl metal,AFiberglass�vAll Polyethylene.uRother(explain)
Dimensions
Capacity: AA gallons
Design ilow. AM gallons/day
Alarm level: Alarm in working order'(. Yes.,jJd Nu
Dale of previous pumping. AJ/�
Comments
(condition of inlet tee. condition of alarm and float switches, etc )
r �
DISTRIBUTION BOX:&we,
(locate on sne plan) n
Depth o: hcu,d �i9 level above outlet nvert _
Comments
(note it level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc )
PUMP CHANABER:aAeA-9
(lou(e on site plan)
Pumps n working order: (Yes or No)-A9
Alarms n working order (Yes or No) /lid
Comments
(note condition of pump chamber, condition of pumps and appunenances, e(c.)
lr•v:.•C 01/25/97) P.q• 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:23 Kimberly Way Marstons Mills Ma
Owner: Craigville Realty
Date of Inspection: 9/30/97
SOIL ABSORPTION SYSTEM (SAS):,
;locate on site plan, if possible; excavation not required. but may be approximated by non intrusive methods)
If not determined to be present, explain
Tree
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:=
leaching,.trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, numbe
Alternative system:
Name of Technology: LEE We-
Comments
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
�r F r a v
CESSPOOLS: 0044'—
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert AA
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: 14,X
Indication of groundwater:
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
77
PRIVY:
docate on site plan)
Materials of construAion: Dimensions:
Depth of solids:
Comments:
Incite condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
� v
v / IS 97) D•g• a of 10
tr• 1••d 0 / /
U,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C 'r
SYSTEM INFORMATION (continued)
Property Address: 23 Kimberly Way Marstons Mills Ma
Owner: Craigville Realty
Date of Impe<tion:
9/30/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
:r'.ciude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (locate where public water supply comes into house)
3 Kim 6er�c w R�c n'le fort ._►'Yl ,�
c�
i
(T-1 •d 04/15/57) P.q• 9 of 10
• SUBSURFACE SEWAGE DISP SYSTEM INSPECTION FORM
C
SYSTEM INFOI: :ION (continued)
Properly Address:23 Kimberly Way Marstons Mills Ma
Owner: Craigville Realty
Date of Inspection: 9/3 0/9 7
e,t�
Depth to Croundwater/`� Feet
Please indicate all the methods used to determine High Croundwater El&.alion:
_ Oo:a.ned from Design Plans on record
_ZObservat.on of Site (Abuning properry, observation hole, basemcrst'simp etc.)
'ZDetermme it from local conditions
Check with local Board of health
Check FEMA neaps
heck pumping records
heck local excavators, installers
use USCS Data
Descr.De , yovr own words how you established the High Croundw.nef-E Ievation (Must be completed)
Used Cape Cod Commission -Map
September 1995
Water Table Contours
And
Public Water Supply
Wellhead Protection Areas/ .
Ir•vl••C 0�/75/971 Y.S or 10
1-rr.nr+—n.rr—•.'.-.rn-aer.nmrv-�+n>l.+.nn.r:•.�.+-.v.r:.r►**r+n*+m-rnV rrv,.r�on irs. �'raTst**�m-s r�+'r'r'r•T-"+- - -
I '1'UNN OF Harnstah.le BOARD OF HEALTH �
SONSURFACF SFHAGF DISPOSAL SYSTEM IN31'FCTION FORM - PART D - CF,RTIFI CAT ION
�_ f•••r.. r .--.,i r--r.�.r:r+,•n:m rs er mt.r r+r'+-rn'r•-:'i^ari'+.ni�nrmr-��r rtr,rmrts-nrnr mn n�mr.n�ro-mr+...r.—r r.- r.�. -.
—TYPE OR PRINT CI.EARLY—
PROPERTY INSPECTED
STREET ADDRESS 23 Kimberly Way Marstons Mills'Mass _
ASSESSORS MAP , BLOCK AND PARCEL 0
OWNER ' s NAME Craigviile Realty
.� PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAME Joseph P. Macomber & 'ion , Inc .
COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066
Street Town or CSty Stet• LIP
COMPANY TELEPHONE (508 ) 775 -3338 FAX ( 508 ) 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa-1 system nt
this address and that the information reported is true , accurate , and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
___ZSystem PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 - 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED* \
The inspection which I have c� reted has found that the system fails to
Protect the j)ublic health and the environment in accordance with Title
5 , , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature - L Date
One copy of this certification must be provided to the OWNER , the BUYER
( where applicable ) and the DOARD OF HEAL711 ,
• If the inspection FAILED , the owner or oparator shall upgrade the ayotem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CNR 16 . 305 ,
partd . doc r
_ l
lJ
7 l�
_ ss byv 3r�ti
THE COMMONWEALTH OF M_A.SSA.CHUSETTS
DEPA.RTNIENT OF ENVIRONIVM-i NT.A L PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualificatigns as required and is hereby
author-ize
(�d to use thee
[� title,
CER ' { D TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the
General Laws _ Issued by The Department of Environmental Protection.
lunc S. 1"9 — ---------- _f
Acting DirCC(Or o! the O c toll of w2tct 1'otlutiot) Control
L
LOCATION -
.---
VILLAGE
APPLICANT + FF;F;_
' (Non-refundable)
ADDRESS TELEPHONE NO .
ENGINEER TELEPHONE NO.
DATE SCHEDULED
(Applicant ' s s i�jn<itur. e )
f• o oo-o 0 ot• o" o^o'o,o o • .'o • o 0 0 .,30 0 • • • • • o • • • • • . • • • . • . o • • • . . . o . . • • o
SOIL LOG
SUB DIVISION NAME DATE ®B
r.:"x_PANSION AREA: YES 1/NO
i ISc)A!,,ii OE' HEALTH
'TOWN WATER�PRIVATE WELL % `"T��J / --___.
err/ ---- I:;_ ,AV:\` OR
SKETCH: (Street name, etc. ,dimensions of lot, exact location of t: :. E, . 1 acid
percolation tests , locate wetlands in proximity to te:-, t
NOTES :
Z-71
i
is
?t
t,
i PERCOLA T ION RATE : /rr/ 24�-2e � s S
;'EST HOLE NO: ELEVATION: TEST,,HOLE N0: };I,I;V I'-fi� �
_ . .
F!�:T
'r 2 G I . Ir111
1 3 3: .
4 m
4 _
5 ..5�,N1l 5
6 16,-e, 6
7 l�2,Br��� 7
B a
9
9
'a 10 1 D
11 11 ,
12 r 12 _-
13 13
14 14
tr 15 � 1 : 115
.:16 i ? 16
({. SUITABLE FOR SUB-SURFACE SEWAGE : - -LEACHING FIELDBLEACHING PITS`
`- LE:ACHING TRENCHES 1-1
i
UNSUITABLE FOR SUB-SURFACE SEWAGE. . REASONS : -. -
NOTE : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST AI'E'I,I. A`I' fON
ORIGINAL: COMPLETED IN ENTIRETY BY P . E . AND RETURNED TO BOARD OE' Hr;:'.',TI j
> -COPY: RETAINED BY APPLICANT
� II
t • _
LA CATION " '� � SEIMAGE PERMIT NO.
VilLAGE
I N S T A LLER'S NAME A ADDRESS ,
e
e U I L D E R OR OWNER
lap
DATE PERMIT ISSUED 717
DATE COMPLIANCE ISSUED 7 G/
0 31
oZ0`
h
.r
No!?6 . 10---- .' Fxs..............................
TH COMMONWEALTH OF MASSACHUSETTS
BOARD F H�. ..�Ar. l
_....J. .......O F....... ....�........... .....�........................................
J
Appliration for Uiupu,ottl Work.5 Tumutrurfinrt Prratit
Application is hereby made for a Permit t Cons uct ( or Repair ( ) an.I dividual Sewage Disposal
System at: f 6,10
j-•--........ .... ... . .. (� x
Ad No.
......... /............. .......... ........................................... .....................................................
w, r ,(� Address
w --••--••-•••-••---, ' ' 1 ��•-----• ...................... .............:I �...717 ................a
co Installer Address
d Type of Building Size Lot. �..Sq. feet
V Dwelling—No. of Bedrooms....... ..................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
P� YP g -•--•-•------------------•-- P ( ) — Cafeteria ( )
Q' Other fi
W Design Flow.............. gallons per person per day. Total daily flow.-.-... ..
••----••------------------gallons.
WSeptic Tank—Liquid capaci ,=.gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. ..... ........... Width ....... Total Length_._...... _._ Total leaching area•.. . -•-• q, ft.
Seepage Pit f_�//,Otl3iameter...... �........ Depth below inlet.......__.. Totalleaching area..�__.___sq. ft.
Z Other Distri utionb ) Dosing tank ( )
Percolation Test Results Performed bY--••-••••-•............................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ri ................... ••••• • • -_..... ... ...............a .
Description of Soil........ . ' �� �..j— f.
-�
f�.t !. ✓ -/ ------------ -.-----•--------•--- -----------•--•-••--•-----
✓ � 1� G`'
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
......---••-••••••••---•--•••-------•--••-•...........•••••---•..........................••-••-•••-••••-•-•••••--••••--....--•••-•••--•-••--•-•-••••-•----••••-••................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary Code—The un rsigned further agrees not to place thin
operation until a Certificate of Compliance haibe is by t e oard'of Health.
Application Approved By.... ..... �./e
Date
Application Disapproved for t f o owing reasons:-------•----•--------------------------------•--........------•-------------•--•------............---•---------
----------------------------------
-------
------•............
----------------
---................
-......----------------------------------.-.--------------------.•..-------------
Date
PermitNo......................................................... Issued-........................................................
Date
SO
No......................... L. FEa..............................
T E COMMONWEALTH OF MASSACHUSETTS
B0ARD0E- H�
....... CJr ........OF............... �
........ ..J
ApplirFa#iun for Uiiipoii ai Works Tontrurtion rantit
Application is hereby made fort t Cons 1 uct ( or Repair (4aln, dividual Sewage Disposal
System at: � j f J
p� �: /
I�et •Ad s r No.
�, Aw � ,Address...... ._..^ ...
WG /............._ �...'---- -----------••---• -... ............. - �/1
Installer Address �" '�
e4 Type of Building Size Lot_ feet
6
U Dwelling—No. of Bedrooms.......... ..:.............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons-----_........._............ Showers ( ) — Cafeteria ( )
a' Other fi ._
--------------------
Design - -- --- ------------ - - -
W Flow............... .......................gallons per person per day. Total daily flow....... ...... .....................gallons.
WSeptic Tank—Liquid capac' .gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. ........ Width................... Total Length........-•......... Total leaching area..,.... ...sq. ft.
Seepage PitAm—f—c�q- -- iameter....... ........ Depth below inlet..... ........ Total leaching area. .."-'. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i•) -----------•------------
-......
-- --------------------------------------------------------------------------------------
Description of Soil........ �..._._.__.f�l `17-Z --�5'���_. ___ .
. ::� / �ew:::::::::::::::::::::
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 TITLE 5 of the State Sanitary Code— The u rsigned further agrees not to place the syste in
operation until a Certificate of Compliance as be n is by a oard of Health.
lollowingg
ed_ ... ........................... ............................
';*a;e
......_...._
Application Approved BY.........,-_ -•------•-...........•------•--•-•-••••----•--••--•............•-•--
..................—Date-------.......
Application Disapproved for the reasons---------------••----•-----...---••--•-------•-------•---------•----•---.._..---•---------- Da.............._
...............•-•-•-•--•----•-••-•••--•-----•--••--•------•---.......•--•••--•-----••.......•------•-•-•--••---••----•--•••------•--••---••-•-•---•-•------------•----...---------••---••------•-•-•-•-
�\ Date
PermitNo......................................................... Issued-------------------- ...............................
�. Dattee
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEAD 1
r'A^ .G'l/L�/J
l
Trr#if it tr of Tontphatta
THIS IS TO CERT h �tnd i �% isposal System constructed (`' ) or Repaired ( )
by ...... ..........
..� ............................. ............... ...
has been installed in accordance with the provisions of T l�'` ie State Sanitar C d/ c�'ribed in the
application for Disposal Works Construction Permit No......................................... dated........................._......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM W4 F CTION SATISFACTORY.
-•-------••-......---•-•------.•----- Inspector .--------•--••.....................
DATE.__...... ...._.... — -•---------
THE COMMONWEALTH OF MASSACHUSETTS
/ BOARD F HE ��i/!�/�� �
mot. G`..
No......................... FEE........................
�iu��asatl k Apn,�
Permission is her ranted.............:••...
to Construct ( . o Rggaitir� ) n Indiv &1 S ya e D Spg6 �f �J' (.�Jat No... -_.. -- -• ... ._... .................................
st t
as shown on the application for Disposal Works Construc ' erm ................... Dated..........................................
.......•-•.. .......... ;.....................................................................-------
DATE_ P7___........ ......P.-/.............................................. -' Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
��1►�GLG FAM(�-`! - 3 BEOROoM
:i ►,!D 'GARBAGE• �jWNDEI�. ,j. � ,
l ��►LY FL-ow ,: Ito x
,:jEPTIG = -A9 %G,P. q
015Po5AL- P1T u5E l000 GAL-
VS WALL AZSGl 1l 5
gpTTOA AQE-A- IcO 5•r - yA/.
NLO
-t�r�,�t,��.� ��-.air.' = 33o G,Po /°/• 7 � , . +t
o tI
?E.ZL4LAT►4Dnl RATE; 1'`(N ZMIN 0t~1-1~j5N
1 1
O F IYIq r�PAS N OF, A(J, z 2 97•d
/.� J
DAVID y ;
WILLIAM y� c" ^�
C. raj w �I u NO 2"973
o` N Y E
Nu, 19334 �?
SUKj .....=K. 2
z
i
I
I
/�_33oS " ' �G /4/• � TOPFNIU= �OZ. f• 1
INV 99 o I
!zsl'GA.L
i Ii v�D/L 1)1ST. INJ:D 5EP'rIC
ux I
TA
I..CACtI INV.��/C�• PIT (NJ•
� �� sQ,va � �(Yu �B•z yB•
GQd✓cL-
j� vJA,KCD
.`I, 6TvN� •
CERTIFIED pL c>7
PRUFILI< -clot-N
1 1A
GOT
WO 5CALF 5cALE �'_ yam . pATE 7-11
it` REF E2.EN GE
f " ` GERTIF`! 'T1-1AT• THE PrZvP �uuJ05NowN
N�RSOW CoMPL'Y5 WITH `( HE S I D�LIN � ,� C--,7— Z /
AUD 6ETE!,ACK 26RL)IfL>✓MENY� oF -dµC-'
14 ►.�T ,��N. �/� 2� oG - z�..
LOG�TED W}TIA N
I?l1 5 T G0OD PL 14
RE6 �A�X T
E 2 �Z e tJ Y
E 1 uN�Y1
o3TERVILL✓
PLL,tiSNET t\ D o E`(oe5
- MASS
I (IJSTRuMENT Sv2vEY tr "TNE. n. I-FSETS Suvu�
` ►1oT C'�E U5EDT0 DETEW^I►�� �.oT �`INES APPLICANT _�Of�i✓ 44N �
J_ 9TOWN OF BARNSTABLE
LOCATION A � f�Y W A Y SEWAGE # DISV- r
VILLAGE ASSESSOR'S MAP & LOT a 7 o7o
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY..
LEACHING FACILITY: (type) 'd f/ (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 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 existA/t on site or within 200 feet of leaching facility) s Feet
Edge of Wetland and ching Facility(If any Hands exist
within 300 fe o a cili Feet
Furnished b r
a
\ s
_ COTU I T
r QO• `
PO D I
Sss, A � s� WAKE
09 156,�
R� sy
\ PATTYS
� • POND
SPUR L
LOT 20 WA y
49 � - .. LOCUS
\ Fo
�, 1 • , r�, .. \ o LOVELL
\ POND
LOCUS MAP
• y w
\ LOCUS INFORMATION
PLAN REF: 280/25
83
. \ TITLE REF: 23928/113
PARCEL ID: MAP 27 PAR 70 -
'' IN E II DOS ZONING•"RF°\: FLOOD ZONE:
0 COMMUNITY PANEL: .25001CO539J +DATED:07/16/14
.0
G .
LOT 21 II I
PARCEL ID: J . - -SEPTIC SYSTEM `
a
#23 = ,
27 70
AREA= 23 733t •, .,
.. , SAVE PAIR PLAN
� .,REPAIR
1000Gp;� ,TqF 8 .90 = / LOCATED AT:
t co
,
NK
A _
DBOX
80.9 OLD
-
9
K
�. APFROX. LP -
- -
a, • C O TU I.T, "M_A
0
- CHARLES E CO LA
'
0.8 PREPARED FOR
• �f1y ��. ` NEW
DBOX
w 3 \` // APRIL 2, 2015
-
80:1
10;. ; \
F
O- N O
D
Rf
.y
� 9
-x
F
:, \\ klF o� EDWARD �s
PUMP, CRUSH, SANDFILL & . 10• �,
co o A
ABANDON AND/OR REMOVE / \ �t>^ STO E
LEACHPIT PER TITLE 5 IF
NECESSARY LOT 22 ~: /,�, No.2 98
BENCHMARK: BAy
COR. BLHD w
EL--83.00
E.
E. A . S.
/ SURVEY, INC.
GRAPHIC SCALE C°� �
� P.O. BOX 1729
20 0 10 20 40 80 SANDWICH, MA. 02563
BUS:(508)888-3619 CELL:(508)527-3600
( IN FEAT )
I inch 20 ft: • SHEET 1 OF 2 J 1739
- ti
a
TOP OF FOUNDATION
ELEV.= 83.9' 4" SCHEDULE } PROFILE OF 2" LAYER OF
.-MIN. PITCH 1/8" PER FOOT 1/8" - 1/2"
SEWAGE DISPOSAL SYSTEM DOUBLE WASHED STONE '.
10' MINIMUM- ; ' (NOT TO SCALE) OR FILTER FABRIC
- EL= 82 0 EL=81.0' '
,. I
EL 80.9
6 MAX. ...r> ....,...,� ....... _
EL 80:8
..6"
..... . ..... .......... ......MAX . .ADD _
-. ,i .. -
•;• RISER &I RISER CONC. INVERT
.;.' COVER I COVER RISER & EL=76.9 '�!vQ' .3.0' ,
10' S=0.04 (IF NEC.) (IF NEC.) EL=80.40 COVER LEVEL
EXISTING PIPE ` 20' S- .10 _ FOR _ r_ FLOW LINE E
EXIST. EXIST. -_
INVERT INVERT 10 ++ INVERT INVERT _ - o� p p p
EL=79.8 EL=79.40' 1 1 4 - - INVERT 0 C� o �_ 0 0 o p »
MIN. ADD EL=79.1.5_ EL=77.13'.-- 6 SUMP EL=76,96' 24" 0 00 o c° 00 36
4' GAS -_ o � 00 � - - � � � 0 c c�
BAFFLE s" BASE OF.MECHANICALLY r. p°o o �' pip, 4�
t4.
r (IF NEC.) ,:3, - .. COMPACTED SAND - "+ - - - -- -- - - - -- --- - -
0 o L
PROP. DB3
7
' DISTRIBUTION 4.0' 8.5'
BOX (H-20) (T )
3/4" TO 1-1/2» i - - 25
' EXISTING
x DOUBLE WASH STONE' - _ z
1 ;000 GALLON TANK 2" 500 GAL. (H-20) DRY WELLS (5.0 X 8 -6 X 3 0 )
(TO REMAIN) SOIL ABSORBTION, (TRENCH FORMATION)
SYSTEM, (S.A.S.) 13 , X 25
-
, I CERTIFY THAT I AM CURRENTLY APPROVED, BY THE DEPARTMENT OF
GENERAL (..NOTES
ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR 15.017 TO CONDUCT BOTTOM OF TEST PIT #2(NO WATER) EL= 69.8
SOIL EVALUATIONS AND .THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. . -BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE. -- - - - - - --
TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS , DESCRIBED IN 310 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY '
FOR SUBSURFACE DISPOSAL OF SEWERAGE. SOIL EVALUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, DESIGN DATA:-
2. ALL ACCESS PORTS OVER TANK TEES SHALL BE '
N„ ARE CCUR A I -ACCORDANCE WITH 310 CMR 15.100 THROUGH ,15.107.
ACCESSIBLE WITHIN 6 OF FINISH GRADE, WITH ANY REMAINING
ACCESS PORTS BROUGHT TO WITHIN 6" OF FINISH GRADE. z NUMBER OF BEDROOMS...
3
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE GARBAGE DISPOSAL
CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE DAVID FLAHERTY, CERTIFIED SOIL EVALUATOR ---No --
UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEN THEY --___ - - - _ - -_ ___ __ _-_- _ _ __ __ TOTAL ESTIMATED FLOW
MUST WITHSTAND H-20 LOADING.
}
(110 GAL 330./BR./DAY X 3 BR.)
4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION * •' '330GPD X 200% = 660 GAL
OF ALL UTILITIES PRIOR TO ANY EXCAVATION. TEST P T I I RESULTS: P #1 46 2 9 USE .EXIST. 1000 GAL. SEPTIC TANK'
5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE
OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE.. _ INSTALL: 2-500.. GAL. DRY WELLS (W/4' CRUSHED •STONE
6. FINISH GRADE SHALL HAVE A MINIMUM OF 2% GRADE SOIL TEST DATE: JANUARY 22, 2015 ,
OVER THE S.A.S. AND DISTRIBUTION BOX. B.O.H. AGENT: DONNA MOIRANDI ON THE SIDES, 4 ,ON THE ENDS)
7. SEPTIC TANK SANITARY TEES SHALL BE CONSTRUCTED OF
SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE SOIL EVALUATOR: DAVID 'FLAHERTY,' R.S.
THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND 11
LOCATED DIRECTLY UNDER THE CLEANOUT MANHOLES. BACKHOE: - RODNEY FISHER ?(MIKE) SOIL CLASSIFICATION................
8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN DESIGN PERCOLATION RATE......9Z_WUI-_/LN.
2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT ,
ELEVATION OF THE OUTLET PIPE. TH#1 EL.= 80.'9 (PERC<2 MPI) BOTTOM @ 54" EFFLUENT LOADING RATE...... �.
9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES. REQUIRED LEACHING "CAPACITY ...330 GAL DAY
10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS ELEV. DEPTH (IN.). HORIZON TEXTURE COLOR MOTTLING OTHER LEACHING CAPACITY PROVIDED:....35_2_ GADAY
BAFFLE, 4 INCHES IN DIAMETER AND CONTRUCTED OF 4' PVC.
11: ALL HIP€§ §HALL §€ WH€DULL 40 PVC KWER PIPE- AND §9:1 9"=9" A LOAMY §AND 19YH/� N/A SIB W���: �1 :9' �') � §IBA§)(:74)d 112 9AL/DAY
FIRST TWO FEET OUT OF THE DISTRIBUTION BOX SHALL 77.9 9"-36" B LOAMY SAND 1OYR6/6 N/A ---- BOTTOM: . (13' x 25')(.74)= 240 GAL/DAY
BE LEVEL:
12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION 69.9 36"-132" C M.COARS. SAND 2.5Y6/3 N/A PERC ' t" TOTAL= 352 GAL/DAY
TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW .
AND APPROVAL. NO GROUNDWATER/NO MOTTLES ENCOUNTERED• 352 GPD PROVIDED - 330 GPD REQUIRED = 22 GPD RESERVE
13. PROPOSED SEPTIC SYSTEM IS WITHIN STATE APPROVED ZONE II '• __- _ __._ _ _- _
CONSTRUCTION NOTES: TH#2 EL. 80.8 ��,ZNOFMgssgc -
ELEV. DEPTH IN. HORIZON TEXTURE COLOR MOTTLING OTHER o DA D 16 SEPTIC• SYSTEM DETAIL PAGE
1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND ( ) - � '
ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING 80.1 0"-8"- A LOAMY SAND 10YR3/3 N/A ----- F JR #23 KIMBERLY WAY
i
WORK ON THE SITE. 77.8 8"-36" B LOAMY SAND - 10YR6/6 N/A ---- 2 COTUIT, MA.
2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE
WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 69.8 36"-132" C M.COARS. SAND 2 5Y6/3 N/A ----- �`�0isTE��O APRIL 2, 2015
IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
3. ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING NO GROUNDWATER/NO ,MOTTLES ENCOUNTERED ' Sgkl7 Rk
TAPE OR A COMPARABLE MEANS. SHEET 2 OF 2., J# 1739