HomeMy WebLinkAbout0005 MAIN STREET (COTUIT) - Health ,5 Main Street
Cotuit
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L. -it does not give you permission to operate. must first obtain the necessary signatures on this form i t - A4ain St Hyannis.
Take the completed form to the Town Clerk's Office, 1st FL, 367 Main St., Hyannis, MA 02601 (Town Hall) and get the. Business Certificate that is
required by law.
` DATE: Fill in please:
APPLICANT'S YOUR NAME/S:
BUSINESS YOUR HOME ADDRESS: C7GU ! '
s/
TELEPHONE # 22 Home Telephone Number 6
NAME OF CORPORATION e
N AME OF'NEW BUSINESS TYPE OF BUSINESS
IS.THIS A HOMEOCCUPATION AS:: NO' `
I
ADDRESSOF.B,USINESS D !. .MAP/PARCEL,`N,UMBER I - . (Assessing)
When starting a new business there are several things you must'do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main-St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has been me of the permit requirements that pertain to this type of business.
L, a ry ivi
Authorized Si nature**
COMMENTS: D OGQ IP
3. CONSUMER AFFAIRS[LICENSINP AUTHORITY)
This individual has t info ed f he licensing requirements that pertain to this type of business.
Aut orized ignature** � � ���� � T�� i2e�g
COMMENTS: e� s C `�CSCJ�
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Commonwealth of Massachusetts �`�
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form =Not.for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Managerpent LLC
Owner Owner's Nam
information is required for every Cotuit MA 02635 9-25-15
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of•the form.
A. General Information
1. Inspector:
Shawn•Mcelroy
Name of Inspector '
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification _ ±gym • : $
I certify that I have personally inspected the sewage disposal system,at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The System: ,
,Passes ❑ Conditionally Passes , ❑ -Fails
❑ Needs Further Evaluaf by the Local.Approving-Authority
` s
9-25-15
I spector'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.
t5ins-3/13 T tle 5 Official Inspection Form:Subsurface Sewage Disposal Page 1 of 17
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J
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Commonwealth & Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: r
® I have not found any information which indicates that.any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the Conditional Pass section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
_ Title 5 Official Inspection Fori
o Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments
5 Main St (AKA 4681�9M Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15- .
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) ;; _ -
❑ Pump Chamber pumps/alarms not operational. System willpass 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 ❑ Y ❑ N• ❑ ND (Explain below):
❑ obstruction is removed ' '! ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑'N El ND (Explain below):
la
❑ ,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):
�I
C) _Further Evaluation is Required by the Board of Health: - �•
❑ Conditions exist which require further evaluation by the Board of,Health in order to determine if
the system is failing to protect public health, safety or the environment.
[ 1.' System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in'a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑' Cesspool or privy is within 50 feet of a'bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°a 5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. City(Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: I
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system'component due to overloaded or
. clogged SAS or cesspool ,
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow'
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
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i
Commonwealth of Massachusetts -�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System -Not for Voluntary Assessments
9 p Y rY
M ,•.''� 5 Main St (AKA 4681 Falmouth Rd) t
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of 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 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.]
y ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.'
® r s The system fails. I have determined that one or more of the above failure
criteria"exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no".to each of the following, in addition to the
questions in Section D. ,
Yes No
❑ ❑ the system is within 400 feet of a surface'ddnking 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 E] ' 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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts x -
. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. Cityfrown State Zip Code Date of Inspection
C. Checklist I
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?
® E 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.
® E 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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts _
Title 5 Official Inspection Form
Subsurface Sewage Disposal System,Form -.Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is Cotuit MA 02635 9-25-15
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: ,
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? , , t ❑ Yes ❑ No
Last date of occupancy: r Date
Commercial/Industrial Flow Conditions:
Type of Establishment: Office
Design flow.(based on 310-CMR 15.203): G25Gpd
' � Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):... 3000Sgft cLD75 gal per 1000 Sq ft
Grease trap present?. ,• ❑ Yes ® No
Industrial waste holding tank.present? ,_ ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
iL
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. City(fown State Zip Code Date of Inspection
D. System Information (cont.) '
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons I
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system`
❑ Single cesspool
❑ Overflow cesspool t
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative.technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval..
❑ Other(describe): -
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts ;
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 5 Main St (AKA 4681 Falmouth Rd) ,
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1987
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction: -
® cast iron ® 40 PVC ❑ other(explain):.'
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 12"
feet
Material of construction: -
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years-
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official -inspection - Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 5 5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness • • 0
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
16"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: '
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date'
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. City/Town State Zip Code bate of Inspection
D. System Information (cont.) ' . . ;. , r. - . .
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
• - , L ,
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: z.w
g gallons per day e
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
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is
required for every Cotuit MA 02635 9-25-15'
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from pit.
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 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
I
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd) r
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. Cityrrown State Zip Code Date of.Inspection
D. System Information (cont.) ,
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level.of ponding,damp soil, condition of
vegetation, etc.):
Leach pit in good condition and holding water at 16" off bottom,with stain line at 20" off bottom of pit.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts .J
Title 5 Official ectiomform Ins� p
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f
5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit. MA 02635 9-25-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) x
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below: .
® hand-sketch in the area below
❑ drawing attached separately
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94-
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
" Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
RJB Management LLC
Owner Owner's Name
information is required for every Cotuit MA 02635 9-25-15
page. City(rown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Service
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2-12-11
Inspector's Signature Date
The system inspector shall submit a copy of this-inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate.regional office of the DER. The original should be sent to the system.owner
and copies sentto 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.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Dispose S stem•Pa e 1 DI
P 9 P UY
Y
t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leakingland if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
--7
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M y 5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): t
❑ 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
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681.Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/ day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes . No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion`of 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 fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be,attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.'
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ .,. .., the system is within 200 feet of a tributary to a surface drinking water supply
Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection
El
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 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is
Cotuit MA 02635 - -
required for every 2 11 11
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ 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 CM 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):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
Sump pump? ❑ Yes ❑ No
Last date of occupancy:
• Date
Commerciallindustrial Flow Conditions:
Type of Establishment: Office
Design flow(based on 310 CM 15.203): 225 GPD
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): 3000sgft@75 Gal per 1000sq.ft.
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
Building is primarily used as real estate office and an office for certified public accountant.
General Information
Pumping Records:
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
w Title 5 official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page_ City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1987
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
18"
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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 12
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years"
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is require or every Cotuit MA 02635 2-11-11
d f
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 20
Scum thickness 0
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
16"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert evidence of leakage, etc.
q 9 :)
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
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 pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit in good condition with standing water 10" and stain line at 20"from bottom of pit.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of'solids layer
Depth of scum layer
Dimensions of cesspool .
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page.13 of 17-
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Fro
+ce
-p-336 $D_ a7
14 T_1976
B-f-3S6
r3 O r
R
t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
IN
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
USGS maps and town maps show groundwater at 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 5 Main St (AKA 4681 Falmouth Rd)
Property Address
Judith Fitzgerald
Owner Owner's Name
information is required for every Cotuit MA 02635 2-11-11
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: -7, Fill in please:
�. x APPLICANT'S YOUR NAME S: lJ%�I�rJM ��' SYt177S
BUSINESS YOUR HOME ADDRESS: E T���z c C C�N�
�� wa
TELEPHONE # Home Telephone Number ,� 2�
NAME OF CORPORATION: Ga y fJ6 `l ?I-- _-Qh�C
NAME OF NEW BUSINESS s4-1LC PUP-N 17VR-,r Ga&fWYPE OF BUSINESS FgA—rl 1 rum ' ->4zL�-yty
IS THIS A HOME OCCUPATION? YES NO G/—
ADDRESS OF BUSINESS 15, nAVJ 57- Co7j 1.7— MAP/PARCEL NUMBER--60 (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1 BUILDING CONJ ISSIO ER'S OF IC
This individul al his fo m of a y rmit requirements that pertain to this type of business.
Au horizad Sign re**
COMMENTS:
2. BOARD OF HEALTH MUST COMPLY WITH.A11
This individual has been info y ed of a ermtt requirements that pertain to this type of business. MATERIALS REGULATIO^'S
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business. _
Authorized Signature*
COMMENTS:
m SASTABL�
To
LQCAA~tQN J q �,- S A KA
6 SEssWs 14,14 i LOT
INS"TALLER'S NAME&PBbNE NO
SEi9IZC TANK C.-A=
I,EACIIl+iG FACILI' (tppa} t� C'
HEI3�QQI�iS _
I3tISIt?�lt QR OiN't�ER
P'ERIITDA�t'E:- CC�NIPLtAI�ICE
Separation Distance B'etvresttc
Maximum Ad�ustec2 GroundwaterTable to the Bottom of .eachingFac�ltty
Private WatarSupplylFell and L eactunm Facility (ff�y ws exut
att sits ur.uiwitn�ftet of les �g fty} t
Edge of WV a- and Leaching 1"iaa't ty. any wetlands exis
within 3(i0'feet n leaching fac:tity3 � �ZrC uW<
Cirweieho�I hV_
® 39Z
0� CIF
Oe ���,
TU OAF BARNSTABLE
,OC-ATION a %� .Sf Ake SEWAGE #
ITLL,AGE t�0 �`` l ASSESSOR'S KAP LOT -- - -
NSTALLER'S NAME&PHONE NO.
;EP"1C TANK CAPACITY
,EACHING FACILITY: (type) _L_!.i... (size) - f..�U0
TO.Of'BEDROOMS
WILDER OR OWNED 3o4 Q//,-re S Ce
'EIMIT®ATL7: COMPLIANCE DATE:
:operation Distance.Between the:
Whim m Adjusted.Groundwater Table to the Bottom of Leaching Facility � �t
yavatc Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) ---Peet
Age of Wedand said Leaching facility(if any wetlands exist
0fee aihn 3 eacwngfciliry)w ` .r,.�feet
'umnished bywy .�ij��liay .
raw. Oip,(.ee
V"9 1"'h r
Q�ek
3's Q-C'33Cf
° `
0 0
Ll Q r
R
E
TOWN OF BARNS
LOCATION `�� jJ/��,r� 5re
� SEWAGE
VILLAGE ¢-
`� �� �� / ASSESSOR'S MAP & LOT 04'qJ
INSTALLER'S NAME & PHONE NO. JD AA '
SEPTIC TANK CAPACITY Zo rya I
LEACHING FACILITY:(type) 14700 (size) X /0
NO. OF BEDROOMS kt�e PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER f r! Nvt,7 ¢1 ! //2 ce 2 �del,
DATE PERMIT ISSUED: i
DATE COISPLIANCE ISSUED:
VARIANCE GRANTED: Yes NO ,,.
y. _ S � y
t Pt.
)� �
d
1
r � ` � '� 0
V. , `/�� �/ ��
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No..�s.:::_��3g � ------ herald � � GPy(`S Fz$..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH l~5�
Gamer 2�
�I...............OF...1 ar lP... t --
XpV iratiun for Diipuual Works Cfuntrurtiun amit
Application is hereby made for a Permit to Construct ( ) or Repair (r✓) an Individual Sewage Disposal
System at:
5!� ......12 4r .......................... -•------•----•._...........----- •••------------•---•-•--..._...-------------•-••--•-•--------....:...........__...................--_..
I walion.Address i ;I Ot N
.�eh�l----------=-------_-------------•------- - ----.-------•----- r/Y1�;--...--. ---- --- ....-------••-•-•..........
� own � -ress
C,••! ........................................
Installer Address �.
d Type of Building Size Lot..�'1} 0p... -..Sq. feet
Dwelling—No. of Bedrooms..._h-a-".4..........................Expansion Attic ( ) Garbage Grinder (4.0)
Other—T e of Building ............... No. of persons....................._..---. Showers — Cafeteria
Otherfixtures ------------------------------------------------------------------------------------------------";;.._.....
b
W Design Flow...... gallons per person per day. Total daily flow............. 2-,.......................gallons.
WSeptic-Tank—Liquid capacity.��ne.gallons Length.......I..... Width--- r_.._.. Diameter---------------- Depth...y.........
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.--......---.--..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by....................................
•--------••-----•-----•--•••••-•---•• Date..........................................
14 Test Pit No. 1................minutes per inch Depth of Test Pit.--................. Depth to ground water........................
G4 Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth to ground water........................
................... ------------..................................................----...........................................................
0 Description of Soil Vic. y...........................•----••........----•-•--•-----••-••-•--••-•----....._...........---•-••------
x
U ---•-----•-------------•---------------•------------•-••-•---------•-•---•--•-------.......•••---..............-•••--•--•••----•-•-••---••-•-. -••---•-••-••--••-•---••--•---•--••---------•-----•---
W ----•••---------------•-....---••-•-•---•--•----•••- .........................................................r
x j/ awn s� �---------------••----••----------••-
U Nature of Repairs or Alt�era ions►Answer when applicable.../ .s.'.y_ -.._.,,� e Ghk •-«p, -_-
W.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL% 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee su d by the l}Qard of healt .
Signed_ .. ................... ( , .../� .. ..?3 ._ �I
Date
ApplicationApproved By•-•--••-••-••--•-----•---------•---• ---•-•-•-•---•--•-......• -•---.....-•-•••------•................
Date
Application Disapproved for the following reasons---------------------------------------------------------------•-----------------------------••-••-----........
..............•••--••-•-............._......---•-•-••---.....................---•-••-----•--••------•--••-••-••••---------•.........--•••••-----•--•---•---••-•---•-----•-•--•---•--------......•-------
Date
PermitNo......................................................... Issued........................................................
} L i
No....................... Fics....5...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF..........................................................................................
Appliration for Rspaaal Works Tons#rurtion Itrrn i#
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
................. _ u ....................... ............ `
...............................
Wa nLw az/q Address
/.a G. ...............
ha` n d®dt�eg�to.f� ' & -- 9._ ..._..•..............•-......---... . -•---••--- .... . ...---..........
......... .. �............
� 7................... .............••••.........74/t� - /S ,------
Installer Address 7-_
Type of Building Size Lot... ...Sq. feet
U
�.. Dwelling—No. of Bedrooms___...A b.`.'.!�...:....................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers
a YP g ..............•------------- P ( ) — Cafeteria ( )
04 Other fixtures .......-•-----------•--••.............•----•--...........-----------•-----...-•-•--•--•-•---••--------•------••-----•-----•-•---......•-•-••......••--
26
W Design Flow........::.::.:........:...................gallons per person per day. Total daily flow.......... _......._.....................gallons.
WSeptic Tank—Liquid capacity./o! .gallons Length....... Width.... .... Diameter................ Depth._`I..........
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.....I............. Diameter....... Depth below inlet.....t............. Total leaching area...�?f....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
1.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f=I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •----------------- -----........---------..............--------------------........._...............................................................
DDescription of Soil.......---•----._._._Sy`r� ------------------•-----.-..----•--------------.-------------------------.-----.----------------•--------•-•-----.-.-------------
U
W ....--------•-•. ......... ................................-•--•---•........................................._.......
U Nature of Repairs or Alteratio —Answer when applicable.... 2.7 � igOo ��s� �_T y/f g �oov l`c r
ids •--------
-=�2c�c�,�i Sri �,S�a-r r -..
.. l ..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n 'ssu by thoard oL .
Signed........ ..........................................•-------...--------............. --- �.r�.------
Date
ApplicationApproved BY.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:...........................................................................................................
-••---•-------•-•----...-•----•-•--------------------•-•----------..............------.........----....--•-•---•-----.......-----•------.....-----...----------------...------...............•••......_
Date
PermitNo......................................................._ Issued-.....................................................
--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................OF.............i�. .J_ J�: ...................................
(In ifirate of T-amphatta
THIS IS TO CERTIFY, That the Individual ewage Disposal System constructed ( ) or Repaired
.t4 _ ( )
by...•...----•---•---........-•--•-------------------------•-...Zoll. .-•----. n_6�:-?D.................:=----------...--•--------•--.................----.................------
, Installer 1
at............... -.. ..._1_elkl -= ._.........
._.......
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as escribed in the
application for Disposal Works Construction Permit No.........._; J0�4 dated-----�.J.��_. ---------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM VK t.L FUNCTION SATISFACTORY.
.. DATE............... �: 1.. ................................ Inspector •---- -----------------•-----------------.......__......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................OF....................................:................................................ pG
No.........3.--.z.10,39 Fes...` C.1.^:..
Disposal Works Tonoiruc#ion ramit
Permission is hereby anted...................: .....................................................................__....
to Construct ( ) or Repair ( .) an Individual Sewage Disposal System
atNo.........................•_.._ . .1`'�. .rail....;�'C. Gp t-„+,. 0.:1# ---=7 '...................................................
Street
as shown on the application for Disposal .Works Construction Permit I o _ !L S.$.-__. Dated------r.f �_.-s���, ...........
ha
DATE.........1.17 S.M2 ...............................................
FORM 1255 A. M. SULKIN, INC., 13OSTON
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: 'F\y E M + tJ Mail To:
BUSINESS LOCATION: rn A r 0 ►7- V+,, D `,) (o 3-S Board of Health
Town of Barnstable
MAILING ADDRESS: rn N �� Ceps, y,� 1(,35 P.O. Box 534
TELEPHONE NUMBER: Hyannis, MA 02601
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
f.,.ir+fyr "-.td,3"'ti:t*.S•,.-,4.r..:,..�, ..+-.4r x..,. +�,,.. ... ..;,,y+�.1.�+..-•..- �....-y...,4r'�^'Yti�F'�'F.�w.$r���'�ft`"+�.�,�+.rl'�"'fix. °E+tLic�s.yy�'`�hfi��•ti:;'�.*S.ti�j..
i
i
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: F\\IE- M A ► Q Mail To:
BUSINESS LOCATION: S m a ► 0 C (A t Board of Health.
, M A t ti Town of Barnstable
MAILING ADDRESS:
� - C v-��%I � . (n a to 35 P.O. Box 534
,TELEPHONE NUMBER: ., Hyannis, MA 02601
CONTACT PERSON: Ga Gc�;
EMERGENCY CONTACT TELEPHONE NUMBER:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO .-"
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Disinfectants;
Hydraulic fluid (including brake fluid) _
Motor oils/waste.oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes .,"� Jewelry cleaners
Asphalt & roofing tar Leather dyes
i
Paints, varnishes, stains, dyesT Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
Paint & varnish removers, de loss Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
f Floor & furniture strippers },r Any.other products with "Poison" Labels
Metal polishes , (including chloroform, formaldehyde,
Laundry soil & stain<re overs hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
f
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
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