HomeMy WebLinkAbout0133 LOVELL'S ROAD - Health 133 Lovells Road, Cotuit _'
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I
L\ Commonwealth of Massachusetts `�s 0`
-, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
z 0 1--�
Property Address
Owner Owner's Name
information is O C9d
required for every _—____ — _
page. City/Town State Zip Code ; 'ai Date of InslSection
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.
Important:When A. Inspector In o ation
filling out forms
on the computer, / A?
use only the tab Kam—
' key to move your Name of Inspector -z1olf
�� ,•�(,,,�Icursor-do not Q.
use the return Company Name
key.
by Company Address
�GdC
City/Town( QO t State� • ---- Zip Code
y
Telephone umbe License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that;;Passes
ys
1.
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
oto
Inspectork Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
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CAI
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/ ?-3 , red
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Property Address
Owner Owner's Name C04Ua
information is
required for every Xi4 va 6is -9
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) Z:�e asses:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
55 1 Subsurface Sewage Disposal System Form Pot for V luntary Assessments
/33
��
Property Address
4�l
Owner Owners Name
information is G' A4 O J / TSi' ,Q ,'1 �
required for every "?�"" t~v✓ O
page. City/Town State Zip Code Date of Insp ction
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N , ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
' a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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i
I
,
Commonwealth of Massachusetts
Title 5 Official -inspection Form
Subsurface Sewage Disposal System Form - of for Voluntary Assessments
133
Property Address
Owner Owner's Name /
information is A.411 / �//77,4 0,)b✓
required for everys
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ LI-1110- 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
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Commonwealth of Massachusetts
�. p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
133 Zo velllj Rol
Property Address
Oy /
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date of Inspect' n
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems. (cont.)
Yes No
❑ ell� 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 '/2 day flow
❑ Lam/ 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.
❑ pello,* Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ar� Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. .
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA-
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
iIa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address � ,
Owner Owner's Name
information is ` O 1
required for every p�
page. City/Town State Zip Code Date of Ins ectiofi
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no" for each of the following for all inspections:
Yes
❑ mping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ the system received normal flows in the previous two week period?
ElHave 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?
�f Ej 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)]
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Commonwealth of Massachusetts
�n - Title 5 Official Inspection Form
+= i- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
tz
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Property Address — j i2e ) i
--ell,
Owner Owner's Name
information is 02 ID
required for every
page. City/Town State Zip Code Date of Ins ection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): —. — Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
IS00 6�4- 1/o I �IC /4=V*4'
Number of current residents: —
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes �o
Seasonaluse? ❑ Yes No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? Yes No
Last date of occupancy: Date
` t5insP.doc•rev.7126l2018 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�y Title 5 Official Inspection Form
ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
133 ed
Property Address
Owner Owner's Name
information is
required for every ('10,
-
City/Town State Zip Code Date of In pecti
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: ---
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - of for Voluntary Assessments
13 ?
Property Address
Owner Owner's Name
information is ha
required for every CV&
page. Cityfrown State Zip Code Date of[Apection
D. System Information (cont.)
4. Ty7of1rem:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
rflo p
❑ 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 co m nt date installed (if knovyn)a source of information:
Were sewage odors detected when arriving at the site? ❑ Yes L_ o
5. Building Sewer(locate on site plan): 3
0
Depth 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.):
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c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
iIc Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Lan../ 5
3 /X
Property Address
Owner Owner's Name u/ A Od�6
information is CO�
required for every —
page. City/Town State Zip Code Date of Insp ction
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: feet
Material o nstruction:
oncrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certifica- X❑ Ye ❑ No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 3411
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 a7
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t404 Ae-6J -c,,. 41 aod 4m�
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Commonwealth of Massachusetts
5 Title 5 Official Inspection Form
111 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Z-ow 9d
v Property Address 9.e, I a'I r
Owner Owner's Name
information is 0 14��� ,/� Q�3�
required for every
page. City/Town State Zip Code Date of Insfectiofi
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
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Commonwealth of Massachusetts
�a Title 5 Official Inspection Form
Subsurface Sewage Dis sal System Fop -Not f r Voluntary Assessments
Property Address 1
QI�
Owner Owner's Name l
information is U` Dd 6 �j [� a-0
required for every _ v l�✓ d
page. City/Town State Zip Code Date of In ection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.).-
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan): �—
Depth of liquid level above outlet invert
�iley
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.):
O
so t l
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
-' I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
Property Address
ej g/ ?
Owner Owner's Name • ]
information is ✓�
required for every u
page. City/I own State Zip Code Date of Ins ctio
D. System Information (cost.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: ——— -----—
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - t for Voluntary Assessments
r 133 ove.111f
Property Address 11
Owner Owner's Name 440.,
information is
required for every
page. City/Town State Zip Code Date of l pectrbn
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
�! ✓� sS /
G t 114ty,
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction --
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.712 612 0 1 8 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
lg� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l33
Property Address
43
Owner Owner's Name
information is
required for every ✓T (/db
page. City/Town State Zip Code Date of Insp ction
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7126l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= 11, Subsurface Sewage Disposal System F)rrp -Not for Voluntary Assessments
133
u Property Address
a `1
Owner Owner's Nam
information is L"10 � 1required for every —
page. City/Town State Zip Code Date of Ins ection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the b ' ing' Check one of the boxes below:
hand sketch in the area below
❑ drawing attached separately
�0N /
3
(-F45
l+4 s
3� �s0 - 4f.5
317
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Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System For -Not for Voluntary Assessments
13.3 Zo 44g
Property Address
cL j,
Owner Owner's Name
information is _ �1/
required for every Qllp2S a
page. City/Town State Zip Code Date of Ins ctio
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
/V
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ bserved site (abutting property/observation hole within 150 feet of SAS)
Checked with local Bo rd of Health- explain:
l L� S - N S •- ads -- �-r��
❑ Checked with local excavators, installers- (attach documentation)
El Accessed USGS database-explain:
You must describe how o ro n
u es blished the high gd water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System For -Not for Voluntary Assessments
Property Address g4e,
Q l l
Owner Owner's Name(,
information is O u,j
required for every
page. City/Town State Zip Code Date of Ins ection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Inspector Information: Complete all fields in this section.
Certification: Signed & Dated and 1, 2, 3, or 4 checked
211/c. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal
isposal System Form -Not for Voluntary /Assessments
r l✓ �../ L...�r L 11 r �V
Property Address
Jt4 '/Gr1
ON ner ON ner's Name
information is Co 4L4 Qd 6 3s _--_ -S
At
required for every
page. Cityfrown State Zip Code Date of In pection
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.
Irnportant.When filling out forms A. General Information .Hf
on the computer,
use only the tab 1. Inspector: U
key to move your
cursor-do not
use the return Nameof Ins pector Cl
key. Z Cl
Company Name
Company Address of
AIA Da 6 4o11-
City/Town r' �D _��/ a State Zip Code
Telephone Nurriber 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 16.340 of
Title 5(310 CMR 16.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Tq rA Lj- - S -:)
Inspect '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.
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1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 133
Zok-ell
Property Address
1414
Cw ner Ov ner's Name
information is (7o A14 Qa&_?S
required for every
page. Cityffown State Zip Code Date of I spectlon
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always com plete 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
Healt h.
*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):
Lr ns.3113 Title 5Official Inspection F orm:Subsurface Sewage Disposal System•Page 2 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/33 love-lls
Property Address
Cw ner Cw ner's Name
information is Co-�L4
required for every
page. City/Town State Zip Code Date of- Mr4ion
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level In the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) 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 mannerwhich 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
t5ns•3/13 Tide 5 Off dad Ins pec Oon F orm Subsu lace Sewage Disposal System•Page 3 of 17
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Commonwealth of Massachusetts
1piTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/.?.3 zone`/s 12d
Property Address
Ow ner Ory ner's Name J
information is C u 1 S a� /
required for every
page. Cityr row n 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
❑ NoBackup 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
❑ Eff,"— Static liquid level in the distribution box above outlet invert due to an overloaded
/ or clogged SAS or cesspool
❑ ,L,7_/ Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
p` In L ovlls 1'�d
Property Address
Owner Onr ner's Name / /l�,Q Oc1635 3 j D 8 /y
information is
required for every
page. C /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:
❑ Lti1 Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ I�' Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ER' Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 2 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 afe triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
000gpd.
❑ L�' 'he system�I . I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system Is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
ins,3113 Title5 Official lnspectionFam Subsurtace Sewage Disposal System-Page5of17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ug
Subsurface Sewage Disposal Systcolt
m Form -Not for Voluntary
lAssessments
123 ►, �- lei
Property Address
Cw ner Cw ner's Name 1
Information is �� 1�N /� o�
required for every
page. Cilyfrown State Zip Code Date of Inspeo ion
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes
❑ umping information was provided by the owner, occupant, or Board of Health
El Were any of the system components pumped out in the previous two weeks?
❑ E 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 WA)
Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
Ld" ❑ 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): Number of bedrooms (actual): /
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): T C70c�
One•3M 3 Title 5 Oflicial 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
`- l33 L ov�e l�s
Property Address /
Owner ON ner's Name Al 0'�Ut o�2�
information is t
required for every --
page City/town State Zip Code Date of I specti n
D. System Information
Description:
a Pc t-13 .T4o-te__
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 2-"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:
m ? ❑ Yes No
Sump pu p
Last date of occupancy: 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 tan
k resent? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
ins,3113 Title50fflcisl InspecticnForm:Subsurface Sewage Disposal system-Page 7of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
V
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/3.3 .Low/Is �d
Property Address /
C✓T/k-7
ON ner Owner's Name
information is Cn L-2 required for every =�-
page. Cftylrow n State Zip Code Date of sped' n
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type
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 VA system by system operator under contract
Cl Tight tank. Attach a copy of the DEP approval.
❑ Other (descri be):
thins•3113 Title 5Official Inspection Form Subsurface Sewage Disposal System•fie 8of 117
P
�C\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�- 123 .L Ol— lls
Property Address
Gi✓ r✓I
Av ner ON ner's Name - l
information is CTL'1 0 /�14 tad Uf 3 d l
required for every
page. City/Town State Zip Code Date of Inspeefion
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
b
Depth below grade: feet
Material of construction:
❑ cast iron 40 PVC ❑ other(explain):
la
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material 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: )I A2
Sludge depth:
trns-3113 Me 501[ticlal Inspection F orm Subsurf aee Sewage Disposal System-Page gof 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address 1
4✓T/vZ
ON Owner's Name /�O /c^I '! (�
Od�O�j�
information is
required for every
page. City/Town State Zip Code Date of Insp ction
D. System Information (cont.)
Septic Tank(cont.)
Ys
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness Q v
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
1106"le
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
�C� ct?N c//7 1? .
Leg �s
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•3113 TItle5 Official lnspectionFart[Subsirface Sewage Disposal System-Page 10d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
14�a r-A'�-7
Cw ner O+v ner's Name �
information is ( /n f � (�a �J/'
required for every l '�
page Ujffown State Zip Code Date of In ection
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):
Dept h bell ow g ra de:
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: ❑ Yes ❑ No
Date of last pum ping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t9ns 3113 TiOe50Mcial Inspea6anForm Subsurface SewageDisposai System Page 11 d 17
{
i
i
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
IY3
Property Address
Ow ner ON ner's Name �jt4i
information isf-
required for every State Zip Code Date of Inspecti n
page. Cityrrown
D. System Information (cont.)
Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 4-7
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.):
4s
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•3113 Title 5OfflGa1 ins pection F orm:Subsulace Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
VTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 20ve /1
Property Address
G✓7�t ✓I
Cw ner on ner's Name
information is b Oo��3j� _,r o 2B 1
required for every
page. City/Town State Zip Code Date o Inspec ion
D. System Information (cont.) `,
Type: 6 X y -Ovvte—
leaching pits Uc;,2- number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
oN /✓1 -� AU �
Q �r k)f Ll N �/�� /I
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
t5rs•3113 T11e50ffldal InspectlonFornt SubsulaceSewageDlsposal System.Page 13d 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
c Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address 11
Cw ner ON ner's Name Ala"
information is required for every Cb 4L.I AW Qd(_?5
page. Cilyfrown State Zip Code Date ofInspectlon
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privylocate on site plan):
( P )
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
One•3113 Title50f8cial Inspection Form Subsurface Sewage Disposal System-Page 14 of 17
L
I
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
IV /23 20,�-6 Ar
Property Address
G✓410
ON n Co ON Name �(�, '� L l
information Is r7-62S /C)g
required for every
page. City/Town State Zip Code Date of nspecton
D. System Information (cont.)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, including ties to
at least two pe anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where p 'c water supply enters the building. Check one of the boxes below.
hand-sketch in the area below
❑ drawing attached separately
vG-�c V
/+mac
/fd - 3) Idd - Vs
If) J?— 50
t5ns•3/13 Tltle5Official Inspection F orm:Subsurface Sewage Disposal System•Page 15d 17
l_
Commonwealth of Massachusetts
,p r
Title 5 Official Inspection Form
Subsurface Sewage Disposal Syste/m Form -/Not for Voluntary/Assessments
Property Address 11117
ON ner ON ner's Name C
4
information Is o ti I �'/ (��3�' S o�-
requiredforevery � /
page. City/Town State Zip Code Date of 19spectiolf
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: pate
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
00l40s 4 i Fs/ Noles
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation: / �✓
�0 ,fie/cJ✓,
S, % •�
O u N G Gt/'ut�
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
tyre•3/13 TiOe50fticial IrepectionForm Subsurface SewageDlspcsal system•Page 16 d 17
A_
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Cp /
Property Address /
/�G✓T r v/ �
Cw ner ON ner's Name
information is
required for every
page. Citylrown 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
9�y tem Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
9 Po Y P 9
tsins•3/13 Tide 50fficial Inspection Form Subsurface Sewage Disposal System-Page 17of 17
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Commonwealth of Massachusetts
Executive Office of Enviromiental Affairs
Dept. of Environmental Protection Jolul Grad
One winter Street,Boston,.Ma. 02108 D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
(508) 564-6813
WILLIAM F.WELD 11
Governor p l�
ARGEO PAUL CELLUCCI -
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART A RECEIVEO
CERTIFICATION
� -� OCT 2 7 1997
133 LoveII ee Cotuit Lot 4 Address of Owner: ��
Property Address: (If different) TOWN OF HDEP ABLE
Date of Inspection: 10/22/97 Jacobson HEALTH DEPT. co
Name of Inspector: John Graci
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
5
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:
This Inspection Is based on criteria defined In Title V
x Passes code 310 CMR 16.303.My findings are of how the system is
_ Condltlona y Passes performing at the time of the inspection.My inspection does
not Imply any warranty or guarantee of the longevity of the
_ Needs Fu th Evaluation By the Local Approving Authority septic system and any of Its components usefulllfe.
Fails
Inspector's Signature: n Date: 10123197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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, B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
Indicate yes,no, or not determined(
tal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
The septic tank is me
CO3Mpliance(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 oxfiltration, 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.
„ (revisedo4n7)97)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 133Lovelis Lane Cotuit Lot 4
Owner: Jacobson
Date of Inspection:10122/97
_ Sew.acte backup or,breakout or high static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"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 is identified below. The Board of Health should be
contacted 10 determine what will be necessary to correct the failure.
Yes No
_ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
_ Discharge or ponding of effluent to the surface of 1he ground or surface waters due to on overloaded or clogged
cesspool.
SAS is in hydraulic failure.
Irerlaed OdR7197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 133 Lovells Lane Cotult Lot 4
Owner: Jacobson
Date of Inspection:10127197
D] SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
— Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 133 Lovells Lane Coluit Lot
Owner: Jacobson
Date of Inspection:10122197
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_x_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x — As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x _ The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, 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.
x _ 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 Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b))
(revised WNW)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 133 Lovells Lane Cotuit Lot
Owner: Jacobson
Date of Inspection:10122197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 g•p.d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: o
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): Yes
Water meter readings, if available:(►ast two(2)year usage(gpd):
n1a
Sump Pump(yes or no): No
Last date of occupancy:Weekend use
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:o gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings. if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last year.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:U gallons
Reason for pumping: n1a
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
1997
r Sewage odors detected when arriving at the site: (yes or no) No
{
(revlaed g4127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 133 Lovells Lane Cotuit Lot
Owner: Jacobson
Date of Inspection:10/22/97
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age o . Is age confirmed by Certificate of Compliance No
Dimensions: l.10'e"H5'7"w5'e" (Yes/No)
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:4•'
Distance from top of scum to top of outlet tee or baffle:5"
Distance form bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined: Measured
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.)
Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: n/a
Material of construction: ,_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rva
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:nra
Distance from bottom of scum to bottom of outlet tee or baffle:Wa
Date of last pumping;d,
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.)
n!a —
BU
ILDING SEWER:
(Locate on site plan)
Depth below grade: 2'6"
Material of construction:—cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction linetown
Diameter. a
(;�eImments: (conditions of joints,venting,evidence of leakage, etc.)
(rsvlsed 04127)97)
f i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 133 Lovells Lane Cotuit Lot 4
Owner: Jacobson
Date of Inspection:111122197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nra
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nla
Capacity: nra gallons
Design flow: nra gallons/day
Alarm level:_nra Alarm In working order?_Yes No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
No
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nla
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)_!o
Alarms in working order(yes or no)_ves
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
Irsvlaed M7197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)' ^
Property Address: 133 Lovells Lane Cotult Lot 4
Owner: Jacobson
Date of Inspection:10l22197
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nra
Type:
leaching pits,number: 2-15W'leachpits
leaching chambers, number:nra
leaching galleries,number: rda
leaching trenches, number,length: rda
leaching fields.number, dimensions:nra
overflow cesspool,number:nra
Alternate system:—rda Name of Technology:_nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pits are structurally sound and functioning property.They were empty at the time of the Inspection.
CESSPOOLS:_
(locate on site plan)
Number and configuration: �a
Depth-top of liquid to inlet invert: rda
Depth of solids layer: rda
Depth of scum layer: Na
Dimensions of cesspool: nra
Materials of construction: Wa
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
nra
a
Comments: (note condition of soil, signs of hydraulic failure,level of ponding. condition of vegetation, etc.)
nra
PRIVY:_
(locate on site plan)
Materials of construction: Na Dimensions: rva
Depth of solids: We.
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
(revised 04/27)97)
L ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contlnued)
133 Lovells Lane Cotult Lot 4
Jacobson
10/22197
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)
A �1 q
G � n
v
(DC
CIA t 4�
' A6 3G
`3 4
CO
Ply 9 of 10
(revlsed04RTl9T)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
133 Lovells Lane Cotult Lot 4
Jacobson
10/22197
Depth of groundwater 12
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
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised04127197) sags 10 of 10
1/6/14 AsBuilt
lv
23 33io �
0 3310
i
TOWN O/F/BARNSSTiABLE
LOCATION �UL�f/S G L't• SEWAGE # 0 g
VILLAGE ASSESSOR'S MAP & LOT
NNSTALLER'S NAME 6 PHONE NO.
�EPTIC.TANK CAPACITY
ro
�y.EACHING FACILITY:(type) G� (size) 4loQ
NO. OF BEDROOMS_PRIVATE WELL OR PUBLIC WATER Gb i
BUILDER OR OWNER &rletlYCA 'YG'�G�O
DATE PERMIT ISSUED:
DATE COUPLIANCE ISSUED; �7 -/1 2- �1
VARIANCE GRANTED: Yes No ✓"
issq l2/intranet/propdata/prebuilt.asp�Qmappar=025053&seq=2 1/2
ti
TOWN OF BARNSTABLE
LOCATION A� SEWAGE # p 7- 30.2
VILLAGE - ASSESSOR'S MAP & LOT
�, Y:G _
N NSTALLER'S NAME & PHONE NO. �s l• �Ct�»U
�NSEPTIC TANK CAPACITY
EACHING FACILITY:(type) (size)
NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER �iob
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
� �, ; ,
36� '? �.
3d
3
�Z
Fimz
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
----.To N................OF.........1!1W914z3T.A,6u:.................................
Appliration for Roposal Works Tonstrurtiun ramit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
Location•Address or Lot No.
................................ ..................................................................................................
a �ner Address Q ' -: -----------------------------------------•---•--------•---------.....---------•---•-•--•----------
Installer Address
Q Type of Building Size Lot.QGtl o._,?.24±Sq. feet
aDwelling—No. of Bedrooms.............._...__._.._......... .Expansion Attic a ( ) Garbage Grinder ( )Other—Type of Building ............................ No. of persons...•....5...... Showers ( ) Cafeteria ( )
Other fixtures ..
W Design Flow...........r•?-_5........................gallons per person per day. Total daily flow....4_4Q........................gallons.
WSeptic Tank—Liquid capacity.1O _gallons Length.10..-47 . Width_._'-�_.�&'. Diameter................ Depth.5•7_1...
�riW Disposal Trench—No..................... Width.................... Total Length.......--....._..... Total leaching area.................... ft.
Seepage Pit No.......2.......... Diameter..�Q."..O.._. Depth below inlet.-_-.1".... Total leaching area.. &'+-.sq. ft.
Z Other Distribution box ( ✓ _ Dosing tank ( )
aPercolation Test Results Performed bY6&F-..4-..15LANU�?_�,�t��
Test Pit No. 1------A......minutes per inch Depth of Test Pit..... ... Depth to ground water....--'l�'.......
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---••---.--•----__------
..........................•----•---*.............._-----_-----------------•---------—-------------------------------------------------------------------
O Description of Soil.---- Dll.1_C'1....•..5AJS1P �..ow..--30......................................................................
x
V ---------------------
•----------------
•-•--------------
•------------
--------------------------------------------------------------------------------------------
--------
-------------
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
------------------------------•---•------..............------------....------..............--•--•-----.....-•-•----------------...--------.....-----.......-----------•-----............---....._---•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewa a Disposal System in accordance with
the provisions of TITL% 5 of the State Sanita Code—The undersigne rt r agrees not to place the system in
operation until a Certificate of Compliance has en issued b the ar o ea
v
Signe
•-. ------------- •. --• ................................
Date
Application Approved By.........
.• - ; .�-_-.--.-_--_•.._..----
l/ --------------------•
Date
Application Disapproved for the following reasons:-----••-------•----------------•---••-----------------••-------•-----------------•---•••-•---•--•-•---•-•------
...............................•-•----------.......------------•---------------------------•-.....---•---.•----•---•--•••••--••-•----•----•--•-----•-•-•-----••--•-------•------------•--•-•---....------
Date
PermitNo.--- 7..- .................-.... Issued_.....................................................
-
Date
! THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NS T A..... ................................. j..
Applirution for Disposal Works Tonutrnrtion Prrutit
Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
tOT
stem at:
4 [_-ovELL: 5 P-OAP .......... :: .�
t A ;Z)Z E- 1 I A I�o�o�,-t�dd�ess � or Lot No.
.................... -1 v ...J...i..(...... ..jv.N................^--._..._..._.... _......-------....-------•-•-------.........--•----...-•---------.................................
Owner Address
W
Installer Address
Type of Building A Size Lot. ..�2_._._..Sq. feet
�-, Dwelling—No. of Bedrooms______________�__-_t__________________.____.-__Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons......_ ............... Showers — Cafeteria
a Othei:_fixtures ____________________________ _
w Design Flow..........__________________________________gallons per person er day. Total daily, flow_-_.�.� __.___.__.._.___________ Ions.
WSeptic Tank—Liquid capacity �.........gallons Length_K .__G--�____ Width__C-�_._-g_. Diameter________________ Depth ...........
x Disposal Trench—NO_ ____________________ Width.................... Total Length.... Total Total leaching area............ ...sq. ft.
� PSeepage Pit No----------
Diameter_ O-0"_- Depth below inlet.. __.... Total leaching area_.���
g -------•--•---..sq. ft.
Z Other Distribution box (� Do ' tank ( )
a Percolation Test Result Performed b .-__A E 4...................... �IZV t~Y' Date___ Nl
- - ��
Test Pit No. I________________minutes per inch Depth of Test Pit...........VS ____ Depth to ground water_.___'-_._
;,.
44 ` Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Pi - ..__i . -----•••-••--••-•-.........................................................
O Description of Soil..... __E O I U("( �jp,►.!D E5 1�( 3�,.
x • - -------•-----------------------------•-•--------••-----•-••-----•-•••----•---------•-------------------------------•-------•-_-•-••
w
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
---------------------•--•----------------------•------------------------------•--.......-------•-•----•----__-__-____---------_•___._____-_.•----•-•--_-__-----•-•-•-•--•-••--•--........._-_.._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL- 5 of the State Sanitar, Code— The undersigne urt r agrees not to place the system in
operation until a Certificate of Compliance has b en issued b :the and of Bali
../�(
Signed �-----��� - ----� -=---- -" ---------------------=' �^.:_.. ................................
/ Date
Application Approved By -----------------------------------------------
Date
Application Disapproved for the following reasons____________________________________________________________•_____-______________._......._..._________.._...._..
-•---•--•.......................•-•------.....-••--•--•------............--•-----•--------.....-----...--'•-....__._.._...---•••-••-----...--•-•-...--•---•---------------•----__._._----------...__-----
Date
PermitNo-----3-•_?__:... ---------------------. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(9rdifiratr of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (>O' or Repairedby ( )
.... • . _ .-sin .......----••------•----------------•---._...---•-------•-------•-•---•-------...----......-•-------•--•--------••--
/ Installer
lias been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....... -7_--_ . . ..... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
6
DATE................t Inspector..... --
�.... .......
THE COMMONWEALTH OF MASSACHUSETTS r
BOARD OF HEALTH
fJ/ 1... mac,- .,,.........OF............. �...........L.......�°. 'J...
No. '..._..... .. FEE--- ......:�.
Disposal via ku notnution rantit
Permission is hereby granted__._. '`
---------------•---------_-..........__._......._........._•----_....
to Construct ( or Repair ( ) an Individu Sewage Disposal System _
at No L_ y.T....� ._.... �? � ...............YI .............••-•------ "
Street
as shown on the application for Disposal Works Construction Permit No.._F7n_k`..2,Dated..........................................
•--•---••--•---••--•--------•----------------•-----•------•--....._._.._._......------•-.......
T-F� ----•- Board of Health
DA
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS -
S YS TEM PROFIL t'
NOT TO SCALE
TOP�FD`N. FINISH GP+ADE CaC�-f F. �VISH GRADE OVER
:a...ee::,: FINISH GRADE OVER D1,13T. BOX' 60. 7 FINISH GRADE OVER
SEPTIC TANK �o. z
LEACHING PI T <00. n
.,o. VARIES
' 4'• " �' " /� " !2" MAX
3 OF 1 8 1 c' PRECAST CONC. OR
o•.. :o:' o. ASHED PEA •,L:o:_:e.:., ...:...
o: .:...•. BRICK 6 MORTAR
OUTLET PIPE LEVEL .: TO 1,2'v BELOW GRADE , '
FOR 2_ FT. . MIN ;e o p:o qe• oia:b eo o°..
7-
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°o 10
C. I. OR PVC TEES
I, .p::'e :0. °a �..D,' ••e r,JCO.Cjjv A'•
BSMT. FLR. 1500 GALLON
n D S TRIBUTION BOX i
EL . 54-on :c :'o' •
o: a INSTALL ON LEVEL BASE 3/4" TO 1-1/2" 0 3•_7, o
o :b NCRETE p: 10
°.o . .:•.;�:o: o PRECAST CO PRECAST
tiHASHED
.e
0 REINFORCED 4
• e ;
CRUSHED I
CONCRETE °t
o. s: STONE y
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I , .�;,o,•O.O;.o.p�.c:a,'O'•.�.'O.o:,•4:•ct•.a•O•••'p;o• 0•:O.O•.• o <>;..4' o:: �;:: ,
o. H— l 0 REINF.
q� �1 --- �o SEPTIC TANS �: o
42 __ �f 1•� cZ� INSTALL ON LEVEL BASE �
j 6 4.=_____- � NO T SXCi�' VA T TO E�., w �g OR °-' ®� ° 'r
' I
48 I E- L 0WEr'� TO REMOVE ALL IMPERVIOUS 5 3- Z"
50- _ _O LL_ Z _O. - 'Z'-O'
�_Q� D MA TERIAL BE�1/EA TH THE LEACHING AREA � °
REPLACE EXCA VA TED MATERIAL WITH
54 / o CLEAN. CLA Y FREE SAND
j A SINGLE Row of HA ts� ED. l O"- O EFFECTIVE DIAMETER
TA17ED."-6,,,,,MAINTAINE AWN t�NSTRI�e `IQN� gyp' 5 WIDE' STAIRWAY
L EA CH. `NG PIT
a L STATE GENERAL NOTES
! �SRIP TO REMAIN
`.. \ o x INSTALL ON LEVEL BASE
� ALL EMBANKMENT AREAS DISTURBED � `^
4 1. ALL EL EVA TIONS SHOWN ARE B4 SrO ON ASSUME D
DURING CONS+'RUCTION To BE ` �"-- 2. AL L PIPES IN THE SYSTEM MUST BE CAS T IRGr'V''
`�� glVk
REVECEra rED TO THEIR ;,�' OR SCHEDULE .40 ,PVC, '
'�'
PREVIOUS SOUS ONDI �.. ''``
` . - �.� 3'. THE BOARD OF HEAL TH MUST BE NOTI�'•IED
WHEN. CONS TRUC TION IS CO���PL ETE PRIOR
y " PERGOLA TION RATE:
, ¢Z TO BA CKFIL L ING
DRYWELLS FOR ROOF // ��' \\ Z M,IN.'/IN.
44 4. ANY CHANGES IN THI� t LAN MUST BE APPROVED�
RUNOFF f7 REo•D.J4e 4(, BY THE BOARD OF HEALTH AND CAPE C ISLANDS WI TNESSED B Y.•
Q �o zT.� - �� Pj'� `�-�.: ?so SURVEYING CO., INC.
INC.
w p �,, C� F• FO C2 C�
5. MATERIALS AND INSTALLATION SHALL BE IN
COMPLIANCE WITH THE. S7T� Try SANITARY �A��y. BRD. OF HEALTH DESIGN DA TA
DA TE.•
pao�c /T CODE TITLE V - AND . ,
4� �. d. J zQ,6 N a' �� RULES AND REGUL A TIONS E L. 9.3 NUMBER OF BEDROOMS 4'
.40 Q�lt s; f �k ' 6. NORTH ARROW IS FROM RECCP0 PLANS AND c1"
IS NOT, TO BE USED FOR SOLAP PURPGSES TO P5 0 I L � GARBAGE DISPOSAL �0
eU 15501L SAL .
.7. V_ ICJ 2�6T p ` �4 ` r 7. FL OOD HAZARD ZONE G a :SA IL Y FLOW �4�
8. WA TER SUPPL Y TU�,1 �I '/��-� z' .
a ru ..SEPTIC TANK PEG D. ( 5c'�C�GAL
7. n EPTIC TANK PROVIDED
s' ` % �>' T 4'. LEA Cfi-1ING PEOUIPED �GPD.
S 500 GAL4ON } r
PRECAST CONCRE E
SEPTIC TA)1 K . I C� ,— S g '5 A Q D
�2 t2P� ; 'IDENALL AREA = ( i 3 S.F.
i AIg.
c
_(_(_,?�S.F.X .5 G/S.F. - 2 8 GP0
^ 6OTTOM OF STAIRWAY BOTTOM �l S.F.
AREA =
• 57 9N(� tR5 TO B5 I'nisiL EGEND .� S.F.X l.o G/S.F. _
r e
ABovt EXIST. �Zouu ti.l O �i`AT E L EL. 47.3 .E t CHINS PROVIDED s ' 7 06PO
PRECAST CONCRE E
LEACH NG PIT PROPOSED :=LEVA TION 15l� 5-GO Q F[) A Z F I Ts = 72-0 C1 p L7
K,
Q (�
9,P_
50--- EXISTING CGNTOUR
24 OBSERVA TION PI T
DISTRIBUTION f'O:
x PROPOSED 'ENA GE DISPOSAL S YS TEM
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