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Home My WebLink About1801 MAIN STREET (COTUIT) - Health /$�D� /1'Iain c'�-e'en-�- - - - - -- -- - - --- �� ;�/ � � ail �- - --- �� ` � � � 1 Bellaire, Dianna From:Stanton, David Sent:Thursday, August 22, 2024 3:46 PM To:Bellaire, Dianna Subject:RE: 54 Lowell Road? 1801 Main Street? Hi Dianne, It looks like for a long time, it has been using two addresses (54 Lowell Rd and 1801 Main st) based on some of the old documents, it appears that the frontage (Engineering uses it for addressing, where the driveway access is) was on Lowell rd and likely why they were using that address. It now looks like they have changed it and it is now officially 1801 Main st Cotuit (units A & B as it has 2 dwellings.) Our records now should all be converted over to the current address of 1801 Main St. Cotuit. Maybe include this e-mail in Laserfiche as the first page so anyone reviewing the documents will see there was an address change. Not sure if we should just delete the 54 lowell rd completely from Laserfiche, or just keep it and add this e-mail so anyone looking at 54 Lowell rd will see it was re- numbered to 1801 Main st, I am fine either way. Thanks, Dave From: Bellaire, Dianna <Dianna.Bellaire@town.barnstable.ma.us> Sent: Thursday, August 22, 2024 1:39 PM To: Stanton, David <David.Stanton@town.barnstable.ma.us> Cc: Bellaire, Dianna <Dianna.Bellaire@town.barnstable.ma.us> Subject: 54 Lowell Road? 1801 Main Street? Dave, I am working on old permits that Sharon scanned going into Laserfiche. Can you shed some light on my email to Debi Barrows below? My tag in Open Gov to Debi: Can you look at this address? I have a bunch of old documents that need to go into laserfiche. The map/parcel on my documents belong to 1801 Main Street, Cotuit and when I place them in Open Gov it comes out to 1801 Main Street. I picked the most recent permit (this one) to see if there were any notes regarding the address. I see that the location on this permit states 54 Lowell Road, Cotuit but when you click on "View Location" it still shows 1801 Main Street. My documents for the septic permit are from 2022 and they state 54 Lowell Road, Do you know if this address is changing to that address? The septic permit# 2022-157. I want to make sure I place this in the correct folder in Laserfiche. Dianna Bellaire Town of Barnstable Health Permit Technician Email: dianna.bellaire@town.barnstable.ma.us Ph# 508-862-4643 Fax# 508-790-6304 1 Bellaire, Dianna From:Stanton, David Sent:Thursday, August 22, 2024 3:46 PM To:Bellaire, Dianna Subject:RE: 54 Lowell Road? 1801 Main Street? Hi Dianne, It looks like for a long time, it has been using two addresses (54 Lowell Rd and 1801 Main st) based on some of the old documents, it appears that the frontage (Engineering uses it for addressing, where the driveway access is) was on Lowell rd and likely why they were using that address. It now looks like they have changed it and it is now officially 1801 Main st Cotuit (units A & B as it has 2 dwellings.) Our records now should all be converted over to the current address of 1801 Main St. Cotuit. Maybe include this e-mail in Laserfiche as the first page so anyone reviewing the documents will see there was an address change. Not sure if we should just delete the 54 lowell rd completely from Laserfiche, or just keep it and add this e-mail so anyone looking at 54 Lowell rd will see it was re- numbered to 1801 Main st, I am fine either way. Thanks, Dave From: Bellaire, Dianna <Dianna.Bellaire@town.barnstable.ma.us> Sent: Thursday, August 22, 2024 1:39 PM To: Stanton, David <David.Stanton@town.barnstable.ma.us> Cc: Bellaire, Dianna <Dianna.Bellaire@town.barnstable.ma.us> Subject: 54 Lowell Road? 1801 Main Street? Dave, I am working on old permits that Sharon scanned going into Laserfiche. Can you shed some light on my email to Debi Barrows below? My tag in Open Gov to Debi: Can you look at this address? I have a bunch of old documents that need to go into laserfiche. The map/parcel on my documents belong to 1801 Main Street, Cotuit and when I place them in Open Gov it comes out to 1801 Main Street. I picked the most recent permit (this one) to see if there were any notes regarding the address. I see that the location on this permit states 54 Lowell Road, Cotuit but when you click on "View Location" it still shows 1801 Main Street. My documents for the septic permit are from 2022 and they state 54 Lowell Road, Do you know if this address is changing to that address? The septic permit# 2022-157. I want to make sure I place this in the correct folder in Laserfiche. Dianna Bellaire Town of Barnstable Health Permit Technician Email: dianna.bellaire@town.barnstable.ma.us Ph# 508-862-4643 Fax# 508-790-6304 r TOWN OF BARNSTABLE LOCATION C I yyl a % h- SEWAGE # y LOS e � VILLAGE `��; ASSESSOR'S MAP & LOT l �S INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /0 & 0 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER `o ,+ S DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: / 1Ag VARIANCE GRANTED: Yes No y! r a r !i Sy /ouid I ( U�04 . r TOWN OF BA STABLE p LOCATION � SEWAGE# O 9� '(V VILLAGE COTv 1 ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY �CJUO LEACHING FACILITY:(type) A% /060(size) c�l STD NO.OF BEDROOMS OWNER A/W Gw—r PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY i-,iya T bn J k►�- � . 'f Y 36 90 MAtn Hovst C ✓ � �, 4 , Sy Jowl I R� OWN OF BARNS ABLE LOCATION / 61 MA,,% Sr SEWAGE# VILLAGE C6 u+, ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY S$ Qb ) cZ LEACHING FACILITY:(type) ize) r, NO.OF BEDROOMS 3 OWNER �eA 2tfsO N\," PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet, Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY FO r Gvt4 r bti 93 ❑ MAi^ s 31 - '400 OGi-a-e- JL TOWN F BrNSTABLE LOCATION ''/ ow-aj /,T0- SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 0/4 —1Y/ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS a PERMITDATE: COIVi CE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Tab e4o 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 Furtiished by .sE+ No. X4� Fee 6 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppficatiou for 33i!5po!5a1 *pgtem Con0tructiou Permit Application for a Permit to Construct( ) Repair(K Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Ca%v ! h�Ai.�r Spa..t c \i� c!' RC, Assessor's Map/Parcel /6 y'�5/ U oc,. I Q„/ CUwo7' Installer's Name,Address,and Tel.No. Designer's Nape,Address and Tel.No. Srucc r/ACG.//7S%c? �/� eq ppc;rvc, S OS(. / Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min required) gpd Design flow provided gpd Plan Date ✓T Number of sheets Revision Date Title `/ Size of.Septic Tank Type of S.A.S. Cc3fi0CaC�LS Description of Soil Nature of Repair or Alterations(Answer when applicable) Rem V-P_ @ ) l t c✓•e 1�o4✓►C e v2 C Dt�c Date last inspected: Agreement: ` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of alth. igne Date (vfl C U aZOO t� Application Approved Date to�/Q 1 Application Disapproved by: Date for the following reasons Permit No. __ �' t�) c-/' Date Issued /® No. Fee /0 - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes pptication for �Bigogor *pgtem Construction Permit Application for a Permit to Construct( ) Repaiir�(K Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No.SL�G�P w� /�/C-� Owner's Name,Address,and Tel.No. SeA"-r vCa\r\,�c-r i�Ctt `J Assessor's Map/Parcel S/y // /� Installer's m Nae;Address,and Tel.No. Designer's Name,Address and Tel.No. '• orvcc 81? I�o-�a S OS(.. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(m`in..require^ gpd Design flow provided gpd Plan Date t ,/y A Number of sheets Revision Date Title Size of.Septic Tank Type of S.A.S. Cc- f 4Cx`j 1 Description of Soil Nature of Repaiis or Alterations(Answer when applicable) A l F"AA r+t, e r- k tC Z Lv Q C 19% ,)r. Lt o P U C t 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 Envii onmeritakCode and not to place the system in operation until a Certificate of + Compliance has been issued by this Board of Health. �gned Date .I vial C /o,,; UO a ApplicationApprovedb. • t Date W �j/Q /4 Application Disapproved by:' Date for`the following reasons i Permit No. Ll'! Date Issued THE COMMONWEALTH OF MASSACHUSETTS `ICI BARNSTABLE, MASSACHUSETTS f � M Certificate of Compliance THIS IS TO CERTIFY,that the Ong-site Sewage Disposal System Constructed ( ) Repaired (//) Upgraded ( ) Abandoned( )by S L n_,r ,, r 17 // / // V at a ll « h_ t, ra 4SL�!,n r.,r//A has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.' -- 4/S_ —dated 4 /,0/6 Installer 1'�kr_ .c r ti c c e .\ Designer #bedrooms 3 " Approved design flow gpd � C The issuance of this permit shall not be construed as a.guarantee that the system will function as designed. Date /,, � ,� ( � � Inspector No. Fee /�U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS migo at �&pgtem construction permit Permission is hereby granted to Construct ( ) Repair ( v)' Upgrade ( ) Abandon ( ) System located at 1-14 1, /_ST and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date (O r�o A Approved by /`---- -----�' r Town of Barnstable �ptr t�Tow do Regulatory Services vSrnB Thomas F. Geiler,Director 9� �9. •�� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 15, 2006 Mr Gerard Henderson 54 Lowell Road/1801 Main Street Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 54 Lowell Road/1801 Main street(Guest House), Cotuit, MA,was last inspected on May 9th 2006, by, James M. Ford, certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Single cesspools automatically fail in the Town of Barnstable.- You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE H DEPARTMENT as A. McKean, R.S., C.H.O. Agent of the Board of Health ` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION uest House Property Address: 54 Lowell ./1801 Main Street otuit MA 02635 Owner's Name: Henderson Owner's Address: �J Date of Inspection: ME 9, 2006 Name of Inspector: (Please Print) James M. Ford =r Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT ` I certify that I have personally inspected the sewage disposal system at this address and that the mf ation 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 -N s Further Evaluation by the Local Approving Authority ✓ Fit Inspector's Signature: Date: Ma p g y 14 2006 The system inspector shall subrZa 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson , Date of Inspection: May 9, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not-evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health;will pass. 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. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years'old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION continued Property Address: 54 Lowell Rd 11801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9. 2006 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL'INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date'of Inspection: May 9. 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation: ✓ Any portion of cesspool or privy is within 10.0 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool.or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. NOTE:SINGLE CESSPOOLS A UTOMATICALLY FAIL IN THE TOWN OF BARNSTABLE. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: Mav 9. 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ — Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ 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(3)(b)]. 5 I i Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 54 Lowell Rd./1801 Main Street Cotut'_t, MA Owner: Henderson Date of Inspection: May 9, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): I DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents: 1 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): _ Private well(taps offthe main house) Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records " Source of information:_ Pumped months prior-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 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: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 i Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9. 2006 BUILDING SEWER(locate on site plan) Depth below grade: None Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: 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.). GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 I , Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit. MA Owner: Henderson Date of Inspection: May 9. 2006 TIGHT or HOLDING TANK: None (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: allons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 ti Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9. 2006 SOIL ABSORPTION SYSTEM(SAS): None (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: Comments(note condition of soil,signs.of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 single Depth-top of liquid to inlet invert: -- Depth of solids layer: -- Depth of scum layer: -- Dimensions of cesspool:_ 5'W x S'T x T bottom to grade Materials of construction: Block Indication of groundwater inflow(yes or no): No Continents (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): The cesspool had Y ofliauid in it The cover was 12"below grade NOTE: Single cesspools automatically fail in the Town of Barnstable. PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: Mav 9. 2006 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. -------------- Gv"-r PT' ❑ I MA►n s gl �ronT 31 aa- 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: Mav 9, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 12'+1-to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 r ulCOMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE. 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A _ CERTIFICATION Main House G✓ l Property Address: 54 Lowell •d./I801 Main Street �. MA 02635 Owner's Name: Henderson Owner's Address: /Jc) ; Date of Inspection: May 9. 2006 c Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford ` Mailing Address: P.O.Box 49 _ T„ 4, Osterville,MA 02655-0049 Telephone Number: (50&862-9400 CERTIFICATION STATEMENT I certify that I have.personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs urther Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature:. Date: May 14, 2006 The system inspector sha\subm4 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not.found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 h Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Lowell Rd,/1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: Ma 9. 2006 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9. 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into.facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or,privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,:provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. NOTE:SINGLE CESSPOOLS A UTOMATICALLY FAIL IN THE TOWN OF BARNSTABLE. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system 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. 4 Page 5 of 1-1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: Ma 9. 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was.provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ✓ Has the system received normal flows in the previous two— Y p week period . ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system.obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? _✓ — Was the site inspected for signs of break out? ✓ — Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ 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(3)(b)]. . 5 f Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9. 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms.(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Private well Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped months prior per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 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: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: Me 9, 2006 BUILDING SEWER(locate on site plan) Depth below grade: None Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Cesspools acting as septic tanks Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 6'W x 6'T x 9'bottom to grade(bathrooms) -5'W x 7'T x 8 5'bottom to zrade (laundry&kitchen sink) Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: 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.): The single cesspool had 2'ofliauid on the bottom The cover was 15"below grade. Solids were up to the inlet pipe Ther e were signs oaast failure. The second cesspool had 5'ofliauid on the bottom The cover was 2"below zrade. There were si ms ofpast failure. GREASE TRAP: .None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): 7 f Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SY STEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Ad p y dress: . 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9. 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day. Alarm present(yes or no): ' Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: Me 9. 2006 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: .2 Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): Could not locate overflow cesspool in the brush CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no) Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit. MA Owner: Henderson Date of Inspection: May 9. 2006 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. GuosT 93 MAin � S rW►T 3 I aa- 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Lowell Rd.11801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9. 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local.Board of Health-explain: topographic and water contours maps .Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ' Using Barnstable topographic and water contours maps, the maps were showing approximately 12'+1-to Around water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 �I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS UV DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A Barn CERTIFICATION Property Address: (54 Lowell Rd./1801 Main Street 'Cotuit. MA 02635 Owner's Name: Henderson Owner's Address: Date of Inspection: May 9, 2006 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Oster_ville,MA .02655-0049 Telephone Number: (508)862-9400 ` CERTIFICATION STATEMENT RT , I certify that I have personally inspected the sewage disposal system at this address and that the inf6nnation reported below is true;accurate and complete as of the time of the inspection. The inspection was performed-based on my k 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: —Mav 14 2006 The system inspector shall subm 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of.use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 f Page 2 of 11 y 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit. MA Owner: Henderson Date of Inspection: Mav 9. 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due.to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit MA Owner: Henderson Date of Inspection: Mav 9. 2006 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 CAM 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Lowell Rd./1801 Main Street Cot uit, MA Owner: Henderson Date of Inspection: May 9. 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributaryto a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy,of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as des cribed 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 failur e. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 d to 15,000 gPd• gP You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public.water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system 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. 4 f Page 5 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9. 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: g Yes No Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the.previous two week period? . ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and,examined?(If they were not available note as N/A _✓ Was the facility or dwelling inspected for signs of sewage back u ? g p ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened;and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: .54 Lowell M../1801 Main Street Cotuit MA Owner: Henderson �. Date of Inspection: Mav 9. 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 1 Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 d x#of bedrooms): Number of current residents: 0 gP ms): 110 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): _Private well(taps offthe main house) .Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5.system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes.,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ 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) r Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 11/9/89-ner as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit MA Owner: Henderson ` Date of Inspection: Mav 9, 2006 BUILDING SEWER(locate on site plan) Depth below grade: None Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: _ Measurinz stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). Cement tees were resent. The li uid level was even with.the outlet invert. There did not aopear to be al si ns o leakage, GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments on ( pumping recommendations,inlet and out let tee or baffle condition,structural rote rt liquid levels s as related to outlet invert,evidence of leakage,etc.): ty, � 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit MA Owner: Henderson Date of Inspection: May 9. 2006 TIGHT or HOLDING TANK: None (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: allons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate.on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was even. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Conunents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 �l I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit MA Owner: Henderson Date of Inspection: May 9, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6710 Qal.)w/2'stone-per desi n plans leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of.technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The leach Pit was dry and clean. There did not a ear to be any si is of failure. The bottom to rade was 8.5'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: None.(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,:condition of vegetation,etc.): 9 l w� Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell U11801 Main Street Cohdt MA Owner: Henderson Date of Inspection: Mav 9. 2006 . SKETCH OF SEWAGE DI SPOSAL 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. 6 k,�' �� p a Q . 3 y 3� 90 t 10 r . Page l l of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Lowell Rd./1801 Main Street Cotuit, MA Owner: Henderson Date of Inspection: May 9. 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 15+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation). Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours mans the mans were showing approximately 15'+/ to ground water at this site. } This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or-guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system,.the inspection,this report and/or any components of the septic system which have not been located and inspected. 11 h CAPE COD t�. Richard Davis rT 1 SSE 1230 Newtown Road COtu1t, M[A O263S 508-420-0260 LETTER OF INITIAL LEAD NON-COMPLIANCE DATE T- f 3 Dear �a-f We, 4-6 This letter is t certify that I inspected the property located at _!�s0/ dliu r�1 S�o vo I :,=apartment no. _f eO s� , and relevant common areas, in the city or town of E'o`fc�l� , for dangerous levels of lead according to 105 CMR 460 .730 (A) through(F) : Procedures For Initial Inspection,Regulations for Lead Poisoning Prevention and Control, and determined that there were VIOLATIONS. The inspection was conducted on Please be advised that Massachusetts law requires that only certain residential surfaces be free of lead paint . (Deleading must be done by a licenced deleader MASS. state law) NOTE: A copy of the report must be on site at the time of re-inspection which is after the deleading process. STRIP ALL WINDOW WELLS OR COVER WITH FLASHING. SEE NOTE FOR FURTHER REQUIREMENTS. DO NOT PRIME OR REPAINT UNTIL THE INSPECTOR HAS SEEN THE BUILDING. NOTE: MASS. GL CHAPTER Ill S.S . 190-199 Requires that : On both the interior and the exterior of any dwelling, loose offending paints or putty, regardless of surface or height, must be removed. The surface should then be sanded, reputtied and repainted with a non-leaded material in order to reduce further deterioration. Any chewable surface within (5) five feet of a standing surface must be stripped to the bare wood and repainted with a non- lead paint. FEDERAL LAW 24CFR Part 35 Dated 1 April 87 requires stripping be done to the (5) five foot level and as above. ** As of above date of regulation Sincerely, it will be the responsibility of the owner to be aware of any future changes in the law. Richard Davis I 1074 Inspector Licence # Report #LL d 0;L 6 G, At the time of inspection children under 6 were living in the house 9'YES O NO O INCONCLUSIYE Co se a� r No.. F�$.75.`..............._ ' ,T," COMMONWEALTH OF MASSACHUSETTS V,BOARD OF HEALTH ------- ..../.-0W.✓1-...............OF........ Appliration for Uh4paaal Workii Tonstrurtion Famit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal L"Sysl.. �.:.... . ...is 1 ar..........-'------ ................/o T Locatio -Address �� or Lot No. .............. lr;.. f:!14�d6�^S�x].s�C.........•............................•.. ••.............�.o{s2€.�l__. 9 _C .. Owner Address a . : ......................... ...............GO1ili LF Installer Address UType of Building Size Lot___ _.&.le.......S-qr-fee�t Dwelling—No. of Bedrooms......... z._.Tw[o_......Expansion Attic 0,A) Garbage Grinder WO) aOther—Type of Building ............................ No. of persons.............._............. Showers ( ) — Cafeteria ( ) Otherfixtures -----------------------------------•--•---------•-----...-----------------•--------------------------------...-------------------••••--••••-••-•-••••- W Design Flow..............................:...-S-•_-gallons per person per day. Total daily flow...............................Z;?r�..gallons. WSeptic Tank—Liquid capacity/oo.o.gallons Length.5.'-:7 `.'... Width.A'-.10"._ Diameter________________ Depth..5__'-&.` x Disposal Trench—NTo..................... Width.................... Total Length.................... Total leaching area............_.._____sq. ft. 3 Seepage Pit No.....OY_t e--------- Diameter.._I C?.'.......... Depth below inlet...s.t.7.......... Total leaching area...cZ.! .7_...sq. ft. Z Other Distribution box (-K ) Dosing tank ( ) Percolation Test Results Performed by._Att.-w..... �ac�.ra.rl.s�... +t.............. Date:__3�un_...1 ;_.l_� fs..__.. ,aa Test Pit No. 1.._._..?�-------minutes per inch Depth of Test Pit......l$fvt Depth to ground water______________________ _ 44 Test Pit No. 2................minutes per inch Depth of Test Pit......1s `.�_.... Depth to ground wat pV_ a --•••--•-•-•••••••--•--•••-••---•-•--•-••-••••••...••••••••••••.....•••••-•••........----••------•-••-•-•----••.........•.... ......O ' ' — a Description of Soil..Tf�. ..f..L2:�9..t?�pssail. - c?Jax ,.l•_r. ..._.7ticet..____.MAJ.. Q x -3 -• � •--ST-EPHEI�-- V .................................................... --�' � T1Y1r�Q. ?..Ftne. evc�. rrs�.c .�(. aJ �: ----------- A1.L M------ " W "i"p�-Z_ _.G.-d'�.ir� il. .5v.1?Sczi.l_y.. .�'1 O1cur�..YY)1 �_ + 0... .-----WILSON------ �. No 3..... U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------- _,o.`��,..:._021 GISTE a -Agreement: A The undersigned agrees to install the aforedescribed Individual Sewage Disposal System 'n or ice with the provisions of iiLE i of the State Sanitar o e—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e n ssued b ;ie board o h lth. , IP Signed. ...•- -----••--• •••-•-•--••••••• .. - at Application Approved By.... . .......... .. :..... g_.__. . .._ /------ Application Disapproved for the following reason ---------------------------------------•------------•------••......--••••............•••••.ate------.------ ................................•-•--- Date PermitNo---------- ----• -~ —------ -- Issued.........................................=------------- No..l.I...._.__ ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......----7'0 cu✓1................OF........f r s 3�? ' ..------------------.... Appliration for Eliopotial Workii TonBtrnrtion ermit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal Systerrm�///a��)t• /(/{j�//�� //�j�/)/� /1 jJ0 G .....,�-.(.�.t:J.1...:-1. � .�? 1_ _!._V.1 .................. ................... 2--- : 3...... ...................._........._......--.. r Location-Address or Lot No. 1Ct9cL2lad!2.a...!...........•............................... �OW.. �.. �t�G�C� ...._.._...............-•---. Owner Address Installer Address Q Type of Building Size Lot--- -------- U Dwelling—No. of Bedrooms.......--------------....T o-__---_Expansion Attic kV Garbage Grinder �o) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) al Other fixtures _________________________________ _ W Design Flow................................... s._._gallons per person per day. Total daily flow------- . a_..gallons. ...__._----------...... WSeptic Tank—Liquid capacity/Q?Q.gallons Lengthks''_-(66 ..... Widths .r 7.._ Diameter............. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....D --------- Diameter.._!O'........... Depth below inlet..!.?_.......... Total leaching area_;L :7....sq. ft. Z Other Distribution box (K ) Dosing tank ( ) '~ Percolation Test Results Performed by..n!� P_.__ t3of��Cr^?�:�_ __. n4._....._..... Date.. �?!.,__l ;__1_S. `1._.._.. a Test Pit No. 1...... _......minutes per Inch Depth of Test Pit...__9-?�......._ De th to ound wa .--------- 44 Test Pit No. 2................minutes per inch Depth of Test Pit-----....6....... Depth to ground W-1 1:4 _ p� O Descri Description of So>l_._l_�?. .'._a-�.._�_ curl _ v i=pt1___4__-.7.,.C1tu.► Ipirc�. `, 3ptu�_• STEPHEN G x p ' , �� r 1 . ACLYN...... m, V 7 l ilti1cc( w �►n� San�f(4 rt?c4 + S r_14. ..................... - --•--- WtL-SOf�t-•----- W -- 4P.-- ----- - .;+. e� e�_ .. VAj_SQ.J_� �p��'.Gl�te�---yYi4��(< �a �� UNature of Repairs or Alterations—Answer when applicable.___..................................................... A9o.F�; Agreement: awi d ��✓ice The undersigned agrees to install the aforedescribed Individual Sewage Disposal System n accordance with the provisions of A. , p 5 of the State Sanitar Co e— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has a issued b ,the board o health. Signed _ jf! �1 ... = pa Da ?( a Application Approved B ........ '-)•�.....--........•--'--------- -------1.-I-�� ......1., �� - Date Application Disapproved for the following reasori�s ......-----"--•-'-'-•...............••--'•--•--•---'•-•'--••......---...................................... jam" - ---------- Date 01- { f KI) )4 PermitNo. .......... ......,�--------_............. Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEARTH.,,, I //!,/!�......OF......,., 1 '. <.3!..:,...'.....vy �.'-....................................... Trrtifirate of Tomplianrr THIS IS TP CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.................... ..-----... ---------------•------•---------------------------•-----------•-----•---•---•------........--•---....---..._....------.... InstalleF- -�.................................. a--------------------•.-----.------------------•.------------- has been installed in accordance witli7the provisions of TI,TIE 5 of The S to Sanitary CoIR as described in the application for Disposal Works Construction Permit No._ . ---------- ...T' dated_-...: __" r f v ? J THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GiA TE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....&Z V.ek�........................••-------_..._. InspectoF ��. 4: -''-- A.......'._..._.. THE COMMONWEALTH OF MASSACHUSETTS OARD OF rHEAL rK ` j .. :..1 .Ire .1�.... OF..... ., :4 . .. . :....._.. T NO _�..._..._. 1.. r FEE.....-7-- . Disposal Vorkp Tonotration fermit - t4 �.Permission is hereby granted................ -��.xZ........ .............:........................................ to Construct (X) or Repair ( ) an IndiviJual Sewage Disposal_System 0 at No------- - . --'••-" ') �j` S • C� n�'./ ------ -- / Street �;1— /� /lka -?as shown on the application for Disposal Works Construction Permit No�,.v._....(.._;/kted--.��J�.. Via-.f............. Board of Health DATE............ --•-•- ........................................................FORM 1255 S & WARREN. INC.. PUBLISHERS _ ,r _ I ' I , t a ltl7s If, _ pC.-A-c, Z7 near t Z e E�) Icst byI Arrow !Encjr SnC, TO v t:Jcll In i F � .Barn cagy , _ - 12.3 41 7 — 7, i Fizc .:>�,�✓ San.+/ ' 27/ r / r.3er%c4%marle S Tc)P a'� Cahe. Lae , El )/o.Ii�S , r, I n ,/,,., { ./!o O �., I r ,` J Gl.1G fiii1✓" I f�✓fJ G✓As/!!I"J _ ... � r3 $ `h $ ��• o ;Pti y , , �, ,h 0 , : , N iV ; gA;.ti ( i do o- ,.,,,,...� +�.,�1 � � ;: � r•'.O t+SG 0 > rt. , I I i ! 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Gaol �? x G on /�L r 7 - rt A , 4f f I I i-, { , # -r p I t F a , Q _.:i ; .. , ;; } ..... r..; , I.. ;. .: I t ;. ...;.,t '. ..., ,. :,�C t 5"I'c'f c.G L.�.Y"1 G,A .�U 1'".UG O✓�w t ,GlVi I' ,Eh Incur_,, "! j , I � , \J.l I ,TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION / OWNER AND INSTALLER INFORMATION ADDRESS: ��D� . /.� MAP NO. PARCEL NO. i—V? OWNER NAME: 'Q �— /' VILLAGE: ��U�r INSTALLATION DATE: U/Ulriyll�cl� BY: r ADDRESS: CERT.- NO. TANK ' INFORMATION A LOCATION OF TANK: CAPACITY P 71 ('%)TYPE 1 AGE �FUEL/CHEMICAL r .p) :r TESTING CERTIFICATION C I PASS C I FAILa '4 DATE ��_' LEAK DETECTION C 030 HECK IF, N/A TYRE/BRAND ZONE OF CONTRIBUTION C I YES C ] NO DATE TO BE REMOVED ) FIRE DEPT. PERMIT ISSUED C ]• YES C 91 NO DATE CONSERVATION Cv] CHECK IF N/A s DATE BOARD .OF HEALTH TAG NO. y ]C ]C J C I DATE .l _ Ti �'S A l 1— PLEASE., PROV I DE A -SKETCH SHOWI NG, THE TANK. LOCATION,. ON THE BACK. OF THIS 'CARD . ,,.'•.r,..r.,�.?., 1i+., ...?. y,.-....s.F...,..r.`�..r_ ..�3 ....fx . ....:an ..__..,�., ,r., .�.k,; ,., ,-,i..... v w,E.:,i".a,d?. ,.1'.«. e: '�! ..r .,T...s�i w., Yc ,. _..J ....o ........,,. ._.... .. .,.,. .,,... ... .,. � � I /�� i '`4' � ��