HomeMy WebLinkAbout0047 LEWIS POND ROAD - Health 47 Lewis Pond Road, _ Cotuit
A= 020-021
•. 1
/ -- TOWN OF BARNSTABLE pp
LOCATION L�� ULwiS r �2 SEWAGE#�->P
VILLAGE ASSESSOR'S MAP&PARCEL
INOTAethR'S NAME&PHONE NO. 7 t-iL lC �� t&v `Go -1^l'1
SEPTIC TANK CAPACITY 1000 .
LEACHING FACILITY:(type) ' (size) 1 WO
NO.OF BEDROOMS 3
OWNER C_`U r
PERMIT DATE: C0M'Ptf "ATE: SP
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within 200 feet of leaching facility) feet
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leaching facility). feet
FURNISHED BY
r
Lewis Pond road
ater
ervice
I 11 57
44
Page 1 of 3 �
Miorandi, Donna POND 4)
..........................
From: Ann Quinlin [annquinlin@yahoo.com]
Sent: Friday, May 30, 2008 1:14 PM
To: Miorandi, Donna
Subject: RE: Question on Cotuit property
Thanks Donna. Yes, the one online at the assessors office. I'll get you a floor plan - I'll have to sketch it out myself.
Ann
Ann Quinlin
RE/MAX Classic
167 Lovell's Lane
Marstons Mills, MA 02648
508-776-4486 Cell
866-770-8361Fox
www.realestatecape.com
---On Fri, 5/30/08, Miorandi, Donna <Donna.Miorandi@town.barnstable.ma.us>wrote:
From: Miorandi, Donna <Donna.Miorandi@town.barnstable.ma.us>
Subject: RE: Question on Cotuit property
To: annquinlin@yahoo.com
Date: Friday, May 30, 2008, 12:32 PM
When you say field card do you mean the one from the Assessor's office? I'll get back to you on Monday once I
you. If it is now actually 3 bedrooms and you get a letter from the owner now that may suffice. Anything may he
PLAN.
Donna
-----Original Message-----
From: Ann Quinlin [mailto:annquinlin@yahoo.com]
Sent: Friday, May 30, 2008 8:48 AM
To: Miorandi, Donna
Subject: RE: Question on Cotuit property
Hi Donna:
When the current owner purchased the property, she purchased it as a 3 BR. The field card shows it as a
a 3 BR if it may in fact be considered only 2. What would the next step be to get a solid decision one way
owner? Is there any reason this could not be called a 3 BR under the new regulations?
I'm not clear on why the field card and as built says 3 BR? .
Thanks,
` Ann
Ann Quinlin s
,
6/2/2008
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V V V A e '
Barnstable Assessing Search Results Page 1 of 3
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New Search "
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Owner: 2008 Assessed
Values:
FREITAS, LIVIA A
47 LEWIS POND ROAD Appraised Value Assessed Value
Map/Parcel/Parcel Extension Building Value: $ 108,900 $ 108,900
020 /021/ Extra Features: $2,400 $2,400
Outbuildings: $400 $400
Mailing Address Land Value: $213,800 $213,800
FREITAS, LIVIA A
Totals $325,500 $325,500
47 LEWIS POND RD Residential Exemption Received=$165,082
COTUIT, MA.02635
2008 REAL ESTATE Tax Information: Tax Rates: (per$1,000 of valuation)
Community Preservation Act Tax $43.51 Fire District Rates Town
Barnstable FD-All Classes $2.04 $6.58
C.O.M.M. -All Classes $1.03 Commei
Cotuit FD Tax(Residential) $432.92 Cotuit FD-All Classes $1.33 $5.80
Hyannis-Residential $1.53 Persona
Town Tax(Residential) $ 1,450.35 Hyannis-Commercial $2.35 $5.80
Hyannis-Personal $2.35 Other R;
W Barnstable-Residential $1.86 Commur
W Barnstable-Commercial $1.86
W Barnstable-Personal $1.86
Total: $ 1,926.78
Construction Details
Building ProperProkpehtyeS ketch & ASBUILT
ty nd
Building value $ 108,900 Interior Floors Hardwood
Style Ranch Interior Walls Drywall
Model Residential Heat Fuel Oil
Grade Average Minus Heat Type Hot Water
Stories 1 Story AC Type None
http://www.town.bamstable.ma.us/assessing/assess/displayparcelO8map.asp?mappar=0200... 5/29/2008
Barnstable Assessing Search Results Page 2 of 3
Exterior Walls Wood Shingle Bedrooms 3 Bedrooms
Roof Structure Gable/Hip Bathrooms 2 Full
Roof Cover Asph/F GIs/Cmp living area 1226
FOR,
Year Built 1930 Replacement Cost $136182 /
1.4,.
Depreciation 20 Total Rooms 7 Rooms I
Land "h
�1 it
CODE 1010
BA&
Lot Size(Acres) 0.22a '° !" BMT
1
Appraised Value $213,800 � g#_
AsBuilt Card N/A
Assessed Value $213,800
''' = View Interactive Maps >
� -
=sue--- -
Sales History:
Owner: Sale Date Book/Page: Sale Pricer
FREITAS, LIVIA A Feb 12 1999 12:OOAM 12060/283 $ 120,000
SULLIVAN, ROBERT V Aug 22 1997 12:OOAM 10912/320 $90,000
NICKERSON, ROSS M; NICKERSON, DOUGLAS A Jul 22 1997 12:OOAM 10862/021 $0
NICKERSON,JEAN S Feb 15 1996 12:OOAM 10064069 $ 1
NICKERSON, NELSON B&JEA 707/599 $0
Extra Building Features
Code Description Units/SO ft Appraised Value Assessed Value
FPL1 Fireplace 1 $2,400 $2,400
SHED Shed 60 $400 $400
Property Sketch
Legend
BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area (Unfinished) FTS Third Story Living Area (Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area UST Utility Area (Unfinished)
(Finished)
FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story
(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story
(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
http://www.town.bamstable.ma.us/assessing/assess/displayparcelO8map.asp?mappar=0200... 5/29/2008
Barnstable Assessing Search Results Page 3 of 3
FOP Open or Screened in Porch TQS Three Quarters Story(Finished)
http://www.town.bamstable.ma.us/assessing/assess/displayparcel08map.asp?mappar=0200... 5/29/2008
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Commonwealth of Massachusetts
-
Title 5 Official Inspecti6n Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Lewis Pond Road y � �
Property Address
Livia Freitas
Owner Owner's Name
information is COtUIt
required for MA 02635- May 16,�2008-
every page. Clty/rown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any -
way.
Important:
When filling out A. General Information '
forms on the
computer,use 1. Inspector:
only the tab key r -
to move your Patrick M. O'Connell
cursor-do not use the return Name of Inspector
key. Septic Inspection Services Co:
Company Name
189 Cammett Road
Company Address
Marstons Mills MA 02648 f
City/Town State Zip Code
508-428-1779 _ SI 12855
Telephone Number License Number
B. Certification t:
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site'
sewage disposal systems. I am a DEP approved system.inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally,Passes ❑ Fails
❑ Needs Further Evaluation Fby-the Local Approving' Authority �
I` May 16, 2008
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 DER 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.
08-119 Freitas.doc•08/06 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
r
Commonwealth of Massachusetts
Title 5 Official In0ellition Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Lewis Pond Road
Property Address
Livia Freitas
Owner Owner's Name
information is COtUIt
required for MA 02635 May 16, 2008
every page. Clty/rown 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 1`5.304 exist.Any failure criteria not evaluated are..
indicated below.
• a s
Comments:
Recommended pumping•tank. Leaching'pit had one foot of'standing water and had never been more -
than half full.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need.to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes; no or not determined (Y, N,'ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the.existing-tank is replaced with a complying septic tank as
approved by the,Board of Health. s -
*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 staticwater level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipes)are replaced
❑ obstruction is removed
08-119 Freflas.doc•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection For"m
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Lewis Pond Road
Property Address
Livia Freitas
Owner Owner's Name
information is
required for Cotuit MA 02635 May 16,.2008
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain: ,
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order-to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is.not functioning in a manner which will protect public health,
safety and the environment:
Cesspool or privy is within'50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland'or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system hash 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.
08-119 Freitas.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�(0 47 Lewis Pond-
Road d
Property Address
Livia Freitas
Owner Owner's Name
information is y ,Cotuit MA 02635 May 16 2008 required for -
every page. City/Town State : Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation.is Required by the Board of Health (cost.):
❑ 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**, e,
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicate
s absent and the,presence of ammonia nitro en and nitrate
p g t to nitrogen is equal to or
less than 5 ppm, provided th.at.no.other failure criteria are triggered. A copy of the analysis must be
attached to this form. '
3.1 Other:
p
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 ttie ground or surface waters
due to an overloaded or clogged SAS or cesspool
0 ® Static liquid'level in the distribution box above outlet"invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in cesspool is less than 6" below invert or available volume is less
than,-day flow
Required pumping' 4 times in the last year NOT due to clogged or
El ® 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.
08.119 Freilas.doc•08/06 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
'( 47 Lewis Pond Road
Property Address
Livia Freitas
Owner Owner's Name
information is
required for Cotuit MA 02635 May 16, 2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No ,
❑ Any portion of a cesspool or privy is within a Zone 1 of la public.well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply.
well. -
El ® 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;ce'sspool 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 suppl
❑ ❑ the system is within 200 feet of a,tributary to a surface drinking water supply;
❑ the system is located.in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
08-119 Freitas.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
r
a
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-,Not.for Voluntary Assessments
.•'° 47 Lewis Pond Road
Property Address
Livia Freitas
Owner Owner's Name
information is
required for Cotuit MA 02635 May 16, 2008
every page. Cityrrown State d Zip Code Date of Inspection
C. Checklist
Check rf the following have been done.-You must indicate"yes"or"no"as to each'of the following:
Yes No y
® ❑ Pumping information was provided by the owner, occupant, or Board of Health,
❑ 0- Were any of the system components pumped out in the previous two weeks?
❑ ® 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 Sig ns.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?-
El Was the facility owner(and occupants if different.from owner)provided with
® information on the proper maintenance.of subsurface sewage disposal systems?
q
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)]
08-119 Freitas.doc•08106 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
°l 47 Lewis Pond Road -
Property Address,
Livia Freitas
Owner Owner's Name
information is
required for Cotuit MA _ fr 02635 May 16, 2008
every page. Citylrown State Zip Code• Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number-of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 pd x# { 330
g
Number of current residents: 0
Does residence liave a garbage grinder.? , ❑' Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑' Yes ® No
Laundry system inspected?
. ❑ Yes ❑ No -
Seasonal use? ❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ®' No '
Last date of occupancy: ' ' One year ago.
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:.
Design flow(based on 310 CMR 15.203): gallons per day(gpd)
Basis of design.flow(seats/persons/sq.ft., etc.): '
Grease trap present? -} ❑ Yes ❑ No
Industrial waste holding,tank present?. ❑ Yes ❑ No
Non-sanitary waste discharged_to the Title 5'systern?' = El Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: �+ Date- ^
. . , .
Other(describe):
S
08-119 Freitas.doc•011106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15,
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 47 Lewis Pond Road
Property Address
Livia Freitas
Owner Owner s Name
information is
required for Cotuit MA 62635
every page. CitylTown May 16, 2008
State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Tank pumped two years ago.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
_ gallons ,
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system `
❑ Single cesspool
Overflow cesspool
❑ Privy
❑ Shared system (yes or,no) (if-yes, attach previous inspection"records,.if any)
Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ ' Tight tank.Attach a copy of the DEP approval. -
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Unknown '
Were sewage odors detected when arriving at the site?'. ❑ Yes ® No
08-119 Freftas.doc•08105
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
47 Lewis Pond Road
Property Address
Livia Freitas
Owner Owner's Name
information is Cotult
required for MA 02635 May 16,2008
every page. Cityrrown - State Zip Code Date of Inspection
D. System Information (pout.) '
Building Sewer(locate on site plan):
- _Depth below grade: 2feet
Material of construction:.
❑cast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feef
Comments (on condition of joints,-venting, evidence of leakage, etc.):
Septic Tank(locate on site plan)':
Depth below grade: 2'
feet
Material of construction: '..
® concrete []'metal ❑fiberglass ❑ polyethylene ❑ other(explain). -
If tank is metal, list age: 4f
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No.
---------------------------------------------------------------------- -
Dimensions: 8.5' long x 5.2'wide- 1000 gal.
Sludge depth: 411
Distance from top of sludge to bottom of outlet tee or baffle
26" -
Scum thickness 3
6"
Distance from top of scum to top of outlet tee or baffle.
Distance from bottom ofscum to bottom of outlet tee or baffle
10"
How were dimensions determined? Measured
08 119 Freitas.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'f 47 Lewis Pond Road
Property Address '
Livia Freitas r
Owner Owner's Name
information is
required for Cotuit MA 02635 _
every page. Cityrrown May 16;2008
` 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.):
Liquid level was found at bottom of outlet invert tees are intact Recommend pumping tank
ease Trap (locate on site plan):
Depth below grade:` s
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):
08-119 Freltas.doc-08106
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
j
Commonwealth of Massachusetts
Title 5 Official Inspection . .
= Fore r'•
m
i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Lewis Pond Road
Property Address
Livia Freitas
Owner Owner's Name
information is
required for Cotuit MA 02635 May 16, 2008
every page. City/Town State Zip Code Date of inspection
D. System Information (cont.):
Tight or Holding Tank(cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per.day
Alarm present: ❑ Yes ❑ No
ry
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: f
Date t,
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
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes• ❑ No
08-119 Freitas.doc•08l06 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts-
Title 5 Official Insp ection Fyorm
Subsurface Sewage Disposal System Form-Not forVoluntary Assessments`
r( 47 Lewis Pond Road
Property Address ,
Livia Freitas
Owner Owner's Name
information is w
required for Cotuit MA . n 02635 May 16, 2008
every page. City/Town State - Zip Code" • Date of Inspection
D. System Information (coat.)M _
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:y
Type
t ® leaching pits <* number. One 6x6 pit.
0- leaching chambers..'"'- number:
0 'leaching,galleries number
❑ : leaching trenches, number, length.
El leaching fields number, dimensions
❑ overfloGi cesspool =, number.-,
innovative/alternative'.system
Type/name of technology:
e
.. :' ': '..a * , fie' ' v a • .,'".. �.: - 1a
" . Comments (note condition,of soil, Signs,pof hydraulic failure, level of ponding damp toll, condition�of
vegetation, etc.): >
µ
Pit had one foot of standing waterat time of inspection'with a high stain,line indicating, it had never '
been more than half full.
08119 Freitas:doc-08/06 a ` 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
47 Lewis Pond Road
Property Address
Livia Freitas
Owner Owner's Name
information is
required for Cotuit MA 02635 May 16, 2008
every page. CltylTown State Zip Code Date of Inspection
f •
D. System Information (cont.)
Cesspools (cesspool must be-pumped as part of inspection) (locate on site plan):
Number and configuration` F •.
Depth—top of liquid to inlet invert ,
Depth of solids layer V
Depth of scum layer'
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow E]' Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site.plan)-,
Materials of construction:'
Dimensions
Depth of solids
Comments(note condition of.soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): y
08-119 Freitas.doc•08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
- ram`, •R • .. r
Commonwealth of Massachusetts
Title 5 Official Inspection ^Form. 3
Subsurface Sewage Disposal System Form-'Not for-Voluntary Assessments }
47 Lewis Pond Road �r r
Property Address ~'
Livia Freitas .
°
Owner Owner's Name
information is
required for Cotuit - MA, . 02635 May 16,.2008
every page. Citylfown State Zip Code, Date of Inspection '
D. System Information (cost.)
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:
. �Lewis-Pond Road .7 4
- a
r ater
w ervice
.
NA \
14%
%
/%/%/%/%/
/
57
1
.s
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments'
47 Lewis Pond Road
Property Address
Livia Freitas
Owner Owner's Name
information is -
required for Cotuit MA 02635 May 16, 2008
every page. Cltyfrown State Zip Code Date of Inspection
D. System Information (cone.)
Site Exam:
® Check Slope d
® Surface water
® 'Check cellar t
® Shallow wells
Estimated depth to ground water: 20
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(abuttin
g g property/observation hole within 1,50 feet of SAS)
❑ Checked with local Board of Health'-explain:
❑ Checked with local excavators, installers-;(attach documentation):-
® Accessed USGS database-explain;
USGS topo map and town GIs. -
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el, 10 and topo map shows property at el 40
08-1 t9 Freitas.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Town of Barnstable
�FtHE 1�
Regulatory Services
BARNSPABLE, ; Thomas F. Geiler,Director
MAS8.
E%6 9. Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIMisclaimer Private Septic Inspections.DOC
i
No. Fee $ 50.00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes.
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Mie;potal *pgtem Con6truction Permit
Application fora Permit to Construct( )Repair�X)upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 47 Lewis Pond Road Owner's Name,Address and Tel.No. 477-5500
Cotuit,Mass. David HEndrick
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. 508-775-3338 Designer's Name,Address and Tel.No. 508-775-3338
J.P.Macomber. & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XX{No.of Bedrooms #3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building Res No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3x110 gallons.
Plan Date 8/1 n/9:7 Number of sheets Revision Date
Title
Size of Septic Tank 1000 Type of S.A.S. 1-1000 pit
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
s P�Figp—. r-�°f``�, `0±ctribut on d1o)r, .�.�e in rt�Cd_n,&c-r,-,00thed the box.
Rewor? c�. the distribution box. Remortered the invert pipe and smoothed the
distribution box.
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 Env' onmental Code and n to place the system in operation until a Certifi-
cate of Compliance has been issue y this B o e 8/19/97
Signed Date
Application Approved by 41a IV Date
Application Disapproved for the following reasons
Permit No. Date Issued
0 j [.1
a 1V0. Fee $ 50VYes
_
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
r
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
01ppYication for Migaar *pgtem Con.5truction Permit
Application for a Permit to Construct( )Repair�X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 47 Lewis Pond Road Owner's Name,Address and Tel.No. 477-5500
Cotuit,Mass. David HEndrick
Assessor's Map/Parcel
u-
Installer's Name,Address,and Tel.No. 508-775-3338 Desi ner's Name Address and Tel.No. 508-775-3336
J.P.Macomber & Son Inc. J. .Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling vo.of Bedrooms #3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building Res No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3x110 gallons.
Plan Date 811 c3!A7 Number of sheets Revision Date
Title
Size of.Septic Tank 1000 4' Type of S.A.S. 1-1000 pit
Description of Soil
loarm.,sand to-medlinit fin- end,
N tture of Repairs or.Alterations(An wer when applicable)
t
.w t w tr - - t_ . _ __jam;<r moothed the
is y-.F; J - •�
}r ZT`�'... bl�tl�RRfiRR
y r�Rew�or e �-e s -- on R"rter a rrvert pipe and smoothed the
` Ci1stri lon box.
,f Date last inspected:
i� Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewagb.disposal system
id accordance with the provisions of Title 5 of the Env'ronmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by this Bo oe f.
V,19/97
Signed Date '
Application Approved by -/ /(/ .0 m Date
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO C RFFY, that the O -s' a Sewage Disposal System Constructed( )Repaired O Upgraded( )
Abandoned( )by .` .b r a n Inc.
at 47 Lewis Pond Road Cotuit,Mass. e n constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. I dated
Installer Designer s
The issuance of this t of a construed as a guarantee that the syI�V�btX-
function asdesign . `
Date Inspector T yb'/ �
50.00
No. — --------------------------Fee
a
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
'Wizpozar *potent Construction Permit
Permission is hereby gwelto f onsFotru�ct(Ro reppair((y5am�U�ppgrade( )Abandon( )
System located at �:otult,MaSs.
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions:
Provided:Construction . us e o ple within three years of the date of thi e it. 6 G
Date: , Approved by �� 0
CERTIFIED SEPTIC SYSTEM REPORT
LOCATION
47 LEWIS POND ROAD
COTUIT, MA 02635
MAP 020 PARCEL 021
PREPARED FOR
SELLER.
MS . JEAN S . NICKERSON n Q
P .O . BOX 131 REC 11VEP
COTUIT, MA 02635
AUG 7 1997
N
m
TOWN OF BARNSTABLE
HEALTH nFPT ,`
BUYER
't9
MR. ROBERT SULLIVAN $
7 EISENHOWER DRIVE
COTUIT , MA
PREPARED BY I
HILLIARD HILLER
P .O . BOX 250
CENTERVILLE, MA 02632
. 508-778-1472
r
• � � , � REcc�ivF
COMMONWEALTH OF MA..SACHLSETTS 7 1997
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 0 AUG
u
TOWN OF BAANSTAr-' e
DEPARTMENT OF ENVIRONMENTAL PROTECTI HEA!TP'
ONE IKINTER STREET. BOSTON. NIA 02108 61 7-292•Si00
s i
WILLIAM F.WELD TRUDY COXE
Govcmo: Scctctary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
C Ine-z L
Property.Address: t 'i -,i lr Address of Owner:
Date of Inspection: '71111 / 7 (f:f different) �Ui�iv a�cj5�
Name of Inspector. .&. Ille-4 4
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15,000)
Company Name:
Mailing Address: �'o gz"x 95z, GYZ-?61'-'
Telephone Number: 5v8 - 77,F
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: K 7X& Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A,�P, or D:
A) SYSTEM PASSES:
I have no found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failu a criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined`, explain wfry not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratron, or tank
failure is imminent The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web httpJiwww magnet.state ma usr0ep
Pnnted on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: y7 Lz':://-s A;�"---v
Owner: 1117S. JG'jh/ S. .vh=-�fil.Sriv < i
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations: 446.4of I 7&Rlp C 1;
broken pipe(s) are replaced
obstruction is removed
✓ distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced ,
obstruction is removed
CI FURTHER EVALUATION I REQUIRED BY THE BOARD OF HEALTH:
Conditions exist whi h require further evaluation by the Board of Health.in order to determine if the system is failir g to protect the
public health, safety and the environment.
1) SYSTEM WILL PAS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PR TECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of.a bordering vegetated wetland or a salt marsh. .
2) SYSTEM WILL FA L UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS UNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The sy em has a septic tank and soil absorption system (SAS),and the SAS is within 100 feet to a surface water supply or
tributa to a surface water supply.
The sy tem has a septic tank and soil absorption.system and the SAS is within a Zone I of a public water supn'v well.
The s stem has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The s stem has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
privat water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates tha
the ell is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less an 5 ppm. Method used to determine distance (approximation not-valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DI SYSTEM FAILS:
You must indicate either "Yes" "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303, The basis
for this determination i identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of se age into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded orclogged SAS or
cesspool.
Static liquid evel in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid dept in cesspool is less than 6" below invert or available volume is less than 112 day floes
Required pu ping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of t mes pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any ponio of a cesspool or privy is within 50 feet of a private water supply well.
Any poriior of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable ater quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform b eria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes or "No" as to each of the following:
The following criteri apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and ety and the environment because one or more of the following conditions exist:
Yes No
the syste is within 400 feet of a surface drinking water supply
the syste is within 200 feet of a tributary to a surface drinking water supply
the syste is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA)'or a mapped Zone II of a
public wa er supply well)
The owner or operator of an such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR S. 0 and 6.00. Please consult the local regional office of the Department for further,information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /O
i
Owner: Alls. f�ii/ .1//G/' 5_,
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
v _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
v _ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered,_ p opened and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) Page 4 of 10
o •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �7 L,�Gd6 S,. _a l2,Q
Owner: A's S.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: .p.d./bedroom for S A.S
Number of bedrooms:-
Number of current residents: d
Garbage gander (yes or no):
Laundry connected to system (yes or no):Y-IL5
Seasonal use (yes or no): /6v
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):
Last date of occupancy: S'J1�,•r � is ,vT�� �Co
COMMERCIAUIN USTRIAL:
Type of establishm nt:
Design flow:lreadgs,
allons/day
Grease trap yes or no)Industrial Waing Tank present: (yes or no)Non-sanitaryscharged to the Title i system: (yes or no)_Water meter if available:
Last date of occu ancy:
OTHER: (Descri )
Last date of occ pancy.
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: t allons
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)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: -41 :F, ?
Sewage odors detected when arriving at the site: (yes or no) �
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ��7 ��w�s /���� /:�-o
Owner:
Date of Inspection: -71
BUILDING S ER:
(Locate on sue Ian)
Depth below de:
Material of co struction: _ cast iron _40 PVC _ other (explain)
Distance fro private water supply well or suction lire
Diameter
Comments: Condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_1e---
(locate on site plan)
Depth below grade:
material of construction: 4-lCo-ncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance -(Yes/No)
Dimensions: S /a n 8 /�'(.o y8� (7Ge-
Sludge depth:Gam; `
Distance from top of sludge to bottom of outlet tee or baffle: /
Scum thickness: U
Distance from top of scum to top of outlet tee or baffle.-
Distance from bonom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) " Le--- &-4., q&
G•�i9/-'/�G�_ �L Ga�i,�ii�,�a Titr�1 7�9,v� �3,� �y�.�,
GREASE TRAP:
(locate on site plan)
Depth below grade:
material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of sc to top of outlet tee or baffle:
Distance from bottom o scum to bottom of outlet tee or baffle:
Date of last pumping: ,
Comments:
(recommendation for p mping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of I kage, etc.)
(re�i..d 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: 1-*15.
Date of Inspection:
TIGHT OR HOLDIt,G TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construct on: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/da\
Alarm level. Alarm in working order_ Yes, _ No
Date of previous pumping:
Comments:
(condition of inlet to condition of alarm and float switches, etc.)
DISTRIBUTION BOX:-L1-1-
(locate on site plan)
Depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working rder: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition pump chamber, condition of pumps and appurtenances, etc.)
(revimed 04/25/97) Pag• 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: 4767 jAn' LF ' S. ,c//Gv6,
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): v
(locate on site plan, if possible; excavation not required, but may be approximated by non intrusive methods)
If not determined to be present, explain:
Type
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS: _
(locate on site plan)
Number and configu anon:
Depth top of liquid inlet invert:
Depth of solids Jaye
Depth of scum laye
Dimensions of( 's ool:
Materials of constr ction:
Indication of grou water:
inflow (c sspool must be pumped as pan of inspection)
Comments:
(note condition f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site ]an)
Materials of c nstruction: Dimensions:
Depth of soli s:
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION..(continued).
Property Address:
Owner: /915.
Date of Inspection: -�
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
w�1 AU
v, o
I
(revised 04/25/97) Pag• 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: y? � iS � /1.0 Colvin
Owner:
Date of Inspection:
Depth to Groundwater meet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how ,you established the High Groundwater Elevation. Must be completed)
s
5"
(revised 04/25/97) Page 10 of 10
I
lily "71.
TOWN OF BARNSTABLE ��
SEWAGE #
vII.LAGE_ l�T�i7
S s ASSESSOR'S MAP & LOT
R' NAME&PHONE NO. /L � , _
SEPTIC TANK CAPACITY �o
LEACHING FACILITY: (type)
NO. OF BEDROOMS (size)BURaM - �
OR OWNER eg s
PERMITDATE: �i/�s�� -, COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Fee
Private Water Supply Well and Leaching Facility 'a t
on site or within 200 feet of leaching facility any wells exist
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of le ng f cility)
Furnished by Feet
I
"Al
�✓�Ta.R uar�
M
1 r
� v
1
a
F -
a
*cob
-�.--- TOWN OF BARNSTABLE
LOCI.—ION �� 1/z'iy/S '��in /<�/a SEWAGE #
VILLAGE Ld?uiT ASSESSOR'S MAP& LOT 6;19a �,O/
R'S NAME&PHONE NO. Z?"
SEPTIC TANK CAPACITY 141-52
LEACHING FACILITY: (type) 1:7/T (size)
NO.OF BEDROOMS 3
B OR OWNER :ff!S T.e,4,v s. .yiGi�. ilSaa.
PERMffDATE: COMPLIANCE DATE: 126Z&2
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �v't 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 le4+ding facility) Feet
Furnished by' ��
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35
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3
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L ® CATION . _ SEWAGE PERMIT NO.
V 1 I./L A G E
INSTA LER'S if A ME A00RE.SS'00000 _
iii
6UILOE OR OWNER •
®.ATE PERMIT ISSUED
DATE COM Pl. IANCE 15SUED
b�
Dui N
No.__ `......774 Fps.... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
/1 ....... - -------............OF..................................... .............................................. :.
'
Appliratiuu for DWpoua1 19orkii Touptrurtiuu ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ��1.�. -S O� .
`7.. ,C off- --- •- . .....................•...............................................................
GG .,�- �
� J�/�_// --- w .................................or Lot No...............................................
..----•- •---•......................
n Address
a . ._.. .. .......... ................................•----•--•-•--:•-...........---•------_._�__.......----------•-••-
Installer Address
d Type of Building Size Lot__ ......................Sq. feet
aDwelling—No. of Bedrooms. Expansion Attic ( ) Garbage Grinder
p4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ------------•••-• ---•-------• - -
W Design Flow............,�'��___________________ lions per person per day. Total daily flow........., _____._.___________gallons.
WSeptic Tank—Liquid capacity � . lons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_ ____________________ Width__ ------- Total Length________.___.,.... Total leaching area....................sq. ft.
Seepage Pit No---------/.._.•___ ameter.....��________ Depth below inlet____.__........ Total leaching area..................sq. ft.
Z Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
aTest 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........................
-'
O Description of-Soil____ _ _e���'�._...___` ..��n _________
UNature of Repairs or Alterations—Answer when applicable.................................................................................................
------- unders,igned
--------------- --------- --- ----•--- ---- --------------._..AgreemenThe agrees to install the aforedescribed Individual Sewage Disposa tem in accordance with
the provisions of iITLi: 5 of the State Sanitary Code _ T-he=u `dersigned-furth r re not toylace the.system in
operation until a Certificate of Compliance has been' d by
Signed...... -• • •-•--• -- /vv Y !•O
Application Approved By------- /L Date
Application Disapproved for the following re ons: ----------------••==--•--- --------
------------------------••---------•-----------------------------------......----•--.......-•-----------------••-....--•--•••--••-------•--••--•-••-•••--------•---•-•------••-••-•--
Date
Permit No. •--�'�- .. .77 4�--•---•---------------------- Issued-......................-----
Date
7ty
No....f................ FEB...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....OF.........................................................................................
ppftrafian for Uhipasal Works (foutitrurtion ramit
Application is hereby maAe-fW a Permit to Construct or Repair an Individual Sewage Disposal
Sy t t
.... ...... ..... .............. ......... ...... ....... ..................................................................................................
'7 or Lot No.
......... ........... . ............. ....... ....... ...............................................................................................
Address
Installer Address
Type of Building Size Lot.............................Sq. Jed#
Dwelling—No. of Bedrooms............................................Expansion'Attic Garbage Grinder
04 Other—Type of Building ..... .....z.;...:.......... No. of persons...,__.._..k................. Showers Cafeteria
04 Other fixtuws ......................................................................................................
< ---------------------------------
Design Flow.............'73o......... allons per person per day. Total d2tily flow............................................gallons.
04 Septic Tank—Liquid capa( V.........gallons Length................ Width__----:---____-- Diameter--.---__--__-__- Depth....--...._.....
Disposal Trench—Ny. .................... Widt ' ith...... I..... Total leaching area.....................sq. f t.
v--------_-----..Total Len
Seepage Pit D................ iameter..................... Depth below inlet._....;—�p........... Total leaching''area.-"..'.�.............sq. ft.,
Z Other Distribution box.� Dosing tank ( ) I .1
Percolation Test Results Performed by........... ............................................................... Date........................................
Test Pit No. I................minutes per.inch Depth of Test Pit.................... Depth to ground water...._..__.........._.._.
Test Pit No. 2................minutes per-inch y Depth'2"fest Pit..... .............. Depth to'ground.water........................
......... ... .7. ...........................................................................................
0 Description of �oil............�..--•-•.............. .........................7................. ----------------��l......7........r --- -----------
.......... .;;..
W ......i��. w.744../ .. r
----------;;4- C_
" W-- i��/-7 ---.;,"!��/--—----------- %Y"
_��---------------------------------------------------------------------------------------------------------------------------------------------------------I.........*---------*"*----------
U Nature of Repairs or Alterations—Answer when applicable.._.................................................................. .........................
----------------------------------------------------------------------
.................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dispo stem in accordance with
the provisions of T 1T LZ 5 of the State Sanitary Codeve- The'. dersigned.fur gr s not to place the,.system in
operation until a Certificate of Compliance has been i/ssued br
S'!
igned..:. ... ......................................................................... ...............................
Date
Application Approved By..................................... ......................................./
p ................... ........................................
Application Disapproved for the following rmlsons:......... Date...............................................................................................
.............................................................................................................................................................................................................
Date
PermitNo........ ............................. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............OF.......... lv'e'es.........................................
Trrtifirate of Tomphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by............/7. A.fAc A............ c:L L,4............................................................................................................................
Installer
at------ -------- ........ n........... ..........................................................................
-------- --- -------
has been installed"in-'accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Wdi� Construction Permit T ---------_-------- dated-------z .......
E CONSTR
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE D AS A GUARANTEE THAT THE
SYSTEM WIL,V FJMCTION SATISFACTORY.
DATE / L )r
---------7' Inspector._ ... .........................................................................
--------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
"�ItItALTH
BOARD Ofx H-
.2 - 1 4 .............. .......................OF.............. ...........................................
No......................... FEE...------...............
Utopoal Workii T11mitrurtion 'pautit
Permissionis hereby granted.........t.......... ................. .. .............10 ...........................................................................
to Constru t ( ) or jZepair an Individual Sewage'Disposal System
7—
at No. .......................... ..................... t.........................................................................................................
...................
as shown on the application for Disposal Works Construction Permit No. ............,�Dated........
'2V
.......................................... ------------------- ------ ........
7-�ryd o h ---ea
DATE-....................................................... ......................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
F9
PAR Real Estate. System - General Property Inquiry Help
Parcel Id: 020 021- - Account No: 794 Parent:
Location.' 47 LEWIS POND RD COT Neighborhood: 03AB Fire Dist: CT
Devel Lot: Lot Size: . 22 Acres
Current Own: NICKERSON, JEANS State Class: 101
I WAMPANOAG DR No. Bldgs: I Area: 1226
�77- 3 y ? Year Added".
MASHPEE MA 2649
Deed Date: 0201*716 Reference: 10064069
January 1st: NICKERSON, JEAN S Deed MMDD: 0296 Deed Ref: 10064069
Comments:
Values: Land' :---:660(.-) Buildings' 57200 E,..-:tra Features:
Road System: 47 Index". 888 (LEWIS POND ROAD ) Frntg: 80
I n d e..-.,.:- ) Frntg:
Control Info: Last Auto Upd9 051797 Status: C Last TACS Update: 051397
Land Reviewed By: Date. OC)(*-')O Bldgs Reviewed By: Date: 0000
Tax *Title." Account'. Taken' Account Status: Hold Status:
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