HomeMy WebLinkAbout0134 MAIN STREET (COTUIT) - Health 334 Main StreetMOM
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No. 11V Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
01ppYicatiou for Yell Cougtructiou permit
Application is hereby made for a permit to Construct(v< Alter( ), or Repair( ) an individual well at:
13Y 3T C.O /UlT _
Location-Address — Assessors Map and Parcel — —
SO VJ /4- G U/a ST CoT l T
Owner
Address
JJeNNIs Jcuw�,e4/ ol�l/�e(�S��contCogTweTl� Oe�O�cs4 t�� 46�jaee (titer O�l !F�/
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well " w G Capacity
Purpose of Well
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of Com liance has been issued by the Board of Health.
Signed ph Id o
Date
Application Approved By
4ate
Application Disapproved for the following reasons:
j�-,�L ,1 Date
Permit No. � , �/ Issued C:�7
Date
--— ------------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of (compliance
THIS IS TO CERTIFY,that the individual well Constructed(✓j, Altered( ), or Repaired( )
by DC-A.)N l3 3,�C,l'j IJ-C
Installer
at <3Y MQ r •j ST- C o(t,t t T
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pr tecti n
Regulation as described in the application for Well Construction Permit No.0 ---q,5 Dated�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
No. �1 / Fee
BOARD OF HEALTH -r
TOWN OF BARNSTABLE
01ppricati-ou—f or Yell Cow5truction Permit
Application is hereby made for a permit to Construct Alter( ), or Repair O an individual well at: r;
C o l U s 7 ..
Location-Address r M �+� -}Assessors Ma'aid Pazcel- -
P
`...,- •' G Ali ZV ``''=}3%`�y,�•_.. �� .,... .x... r--.+csr....9.y .y-ty:--ham ># -" '� lj 4J '..V 1x
Owner �. AddressCD
:,; -
J`�
u�I
1/E NN/S SCC1 u>.�P1� / Cbr
t�'P���.� r�i- 1�C0 ST A6 0&6,,rss-
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well /w C Capacity
Purpose of Well !f s c Tug
Agreement: s`,
F V,
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of Compliance has been issued by the Board of Health.
SignedI*o•
Date +�
c_
Application Approved By
`Date
0
Application Disapproved for the following reasons
Date '
s,
Permit No. l/�.��� � Issued
Date
BOARD OF-HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance—
a. ..' .. ,..r;.. -...a ......w.Y' „.Nr„�,,,;.,..n., t v:..,.re. r..N.,.n.•,•�..,:.,,r-. a�ram. •++ _ n.. .„� ` ,r .. _ t•'
..:prfrpji`"av�W+•n. •+..wnw""Rvw,
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THIS IS'TO CERTIFY,that the individual well Constructed(v), Altered( ), or Repaired( )
by PA
a Installer t s
at / 31-1 ttlG r 1-j T C G>T� i T.
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection r
Regulation as described in the application for Well Construction Permit No.L^�bCW L Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL t
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
BOARD OF HEALTH
TOWN OF BARNSTABLE
Iverr Construction Permit t
No. Fee
Permission is hereby granted to Dew 3 CCa vvtI_j c t
Installer
to Construct(4; Alter( ), or Repair O an individual well at:
Street
as shown on the application for a Well,,Construction Permit.No.d �,�.�.• "�� � `Dated
Date t �' Approved By`•. y
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Town of Barnstable Barnstable
�. Regulatory Services Department
MUMSrA13 j�"a�I.F
MASS,.i639• Public Health Divisi`� on
�Fn µay 200 Main Street,Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL47015 1730 0001 4988 0176
March 22, 2018
Perry, Leroy J Jr&Bonnie
134 Main Street
Cotuit,MA 02635
Dear Mr. and Ms. Perry,
On March 21, 2018,the Town of Barnstable Board of Health voted to eliminate Section
360-9.1 of the Town of Barnstable Code. This means septic system inspections no longer
fail based solely on the observations of the liquid levels inside leaching pits.
Recall that the septic system located at 134 Main Street, Cotuit,MA was inspected on
02/fC20L8Lby Michael DiBuono, certified Title V Septic Inspector for the State of
Massachusetts. The inspection of your septic system showed that the system had failed
based upon the liquid level in your leaching pit. However due to the elimination of this
particular provision, it is now suggested that you have your septic system evaluated again
in approximately7six'm�onths-to-oneyea 2,
If you have any questions,please contact me at 508-862-4644.
Sincerely,
Thomas McKean, S., CHO -
Agent of the Board of Health
CC: Michael DiBuono
•
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\134 Main Street Cotuit doc
Town of Barnstable Barnstable
°# Regulatory Services Department
• BAANSIABI.F-
�. Public Health Division
i639. m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4988 0176
March 22, 2018
Perry, Leroy J Jr&Bonnie
134 Main Street
Cotuit,MA 02635
Dear Mr. and Ms. Perry,
On March 21, 2018,the Town of Barnstable Board of Health voted to eliminate Section
360-9.1 of the Town of Barnstable Code. This means septic system inspections no longer
fail based solely on the observations of the liquid levels inside leaching pits.
Recall that the septic system located at 134 Main Street, Cotuit,MA was inspected on
02/28/2018 by Michael DiBuono, certified Title V Septic Inspector for the State of
Massachusetts. The inspection of your septic system showed that the system had failed
based upon the liquid level in your leaching pit. However due to the elimination of this
particular provision, it is now suggested that you have your septic system evaluated again
in approximately six months to one year.
If you have any questions,please contact me at 508-862-4644.
Sincerely,
Thomas McKean, S., CHO
Agent of the Board of Health
CC: Michael DiBuono
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\134 Main Street Cotuit.doc
'a 067:3 - Ott
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
134 Main st
Property Address
Bonnie Perry
Owner Owner's Name UJ
information is
required for every Cotuit t/ Ma 02635 2/28/18
page. Cityrrown State Zip Code Date of Inspection x°
CID
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.
Impgoutforms When
fillip out f A. General Information on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
r� Company Name
35 Content Ln
Company Address
Cotuit MA 02635
City/Town State Zip Code
508-364-9587 SI 13522
Telephone Number License Number
I
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/4/18
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
f
pfr THE TOy,
Town of Barnstable
Regulatory Services Department
Public Health Division
200 Main Street,Hyannis MA'02601
Ogee 508-862-4644 Richard Sc4 Director
FAX 508-790-6304 Thomas A.McKean,CEO
Feb 6, 2007
Rev. 5111116
DEADLINES TO REPAIR FAILED.SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15,000) _
An``x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
o Discharge or ponding of effluent to the surface of the ground
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe
o Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE(1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis.'(This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
q Single'Cesspool
❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
caching prt or cesspool_with-high liquid level;<12"below inlet(per Town Code
§360 9.1)
❑Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline: _
Q:ISEPTICOEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ 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 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts �.
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. Cityrrown 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 '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. CityrFown 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
❑ ❑ 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.
t5ins-3/13 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 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•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
134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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 ears usage d 127 Gpd
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ 'Yes ❑ No
Industrial waste holding 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
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M .'s 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Not provided
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1993
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
u - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18 '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
24"
Scum thickness 3-1
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick
How were dimensions determined? Tape Measure
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 Traplocate on site plan):
( P )
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
f -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. Cityrrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts ,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
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 NA
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No*
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:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
r.
Commonwealth of Massachusetts ,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit has approximately 9" seperation to invert pipe. Staining indicates level has been up to invert
pipe
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
r -
Commonwealth of Massachusetts ,.
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
page. Cityfrown 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.):
i
t5ins•3113 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
M 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
a
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M •''r 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 2/28/18
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: TBD at time of perk test
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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
3/6/2018 Assessing As-Built Cards
•
j.C,, TOWN OF BARNSTABLE
LOCATION 13`1 ~117 5'v4- SEWAGE#_2.3_V TY
VILLAGE n /i ASSESSOR'S MAP& LOT
INSTALLER'S NAME& PHONE NO.
SEPTIC TANK CAPACITY /OOU
LEACHING FACILITY-.(type) rat I (size)_/One)
NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: $ j9G3
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No V
r
I`
III /
, A t
!� t
http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=023011&seq=1 1/2
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 134 Main st
Property Address
Bonnie Perry
Owner Owner's Name
information is
COtuit
required for eve Ma 02635 2/2 /q every 8 18
Cit (Town page. Y State Zip Code Date of InsP ection
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
O
T ,
03 Certified Mail Fee ;is
Q'
..r
Extra Services&Fees(check box,add fee as appropdate) +n
0 Retum Receipt(hardcopy) $rq C'1
O ❑Return Receipt(electronic) $ PO rk
r ❑Certified Mail Restricted Delivery $ H f
II O []Adult Signature Required $
❑Adult Signature Restricted Delivery$ .'t p Y i.i C3 Postagr —
rn $
� Total PI
t.n Sent To PERRY, LEROY J JR & BONNIE
O Street 134 MAIN STREET' ._...
________ COTUIT, MA 02635
`7 ary,sra
.. ... — ..
Certified Mail service provides the following benefits:
o A receipt(this portion of the Certified Mail labeq. for an electronic return receipt,see a retail
■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. USPS®-postmarked Certified Mail receipt to the;
■A record of delivery(including the recipient's retail associate.
signature)that is retained by the Postal Service- Restricted delivery service,which provides
for a specified period. delivery to the addressee specified by name,or`
to the addressee's authorized agent.
Important Reminders. Adult signature service,which requires the
o You may purchase Certified Mail service with r
y P signee to be at least 21 years of age(not ,
First-Class Mail®,First-Class Package Service®, available at retail).
or Priority Mail®service. Adult signature restricted delivery service,which
■Certified Mail service is notavailable for requires the signee to be at least 21 years of age
international mail. and provides delivery to the addressee specified
■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However,the purchase (not available at retail). r:
of Certified Mail service does not change the s To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark If you would like a postmark on
■For an additional fee,and with a proper this Certified Mail receipt,please present your
endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record. Certified Mail receipt,detach the barcoded portion
of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.
electronic version.For a hardcopy return receipt,
complete PS Form 3811,Domestic Return.
Receipt;attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
PS Form 3800,April 2015(Reverse)PSN 7530-02-000-9047 ,
J
,
0 Complete items 1,2,and 3. A Signature
■ Print your name and address on the reverse X ❑Agent
so that we can return the card to you. ❑Addressee
® Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery
or on the front if space permits.
1 r D. Is delivery address different from item 1? ❑Yes
If YES,enter delivery address below: ❑No
LP�ERRRIY-LEROY J JR & BONNIE
MAIN STREET
U IT, MA 02635
II I OIII�I I II I�I I II II II I I i IIIII I II I DI( II III 3. Service TYP® ❑Priority Mail I
❑Adult Signature ❑Registered MaIlIITmTM
❑Adult Signature Restricted Delivery 0 Registered Mail Restricted
Certified Mail@
9590 9402 1933 6123 1784 84 O Certified Mail Restricted Delivery Retu Receipt for
❑Collect on Delivery Merchandise
2. Article Number(Transfer from Io..r..e!-�- "Delivery Restricted Delivery ❑Signature ConfinnationT
❑Signature Confirmation
7 d 1'S =1 T 3 B 0 1' 469 8'8 017 6 ?. _11 Restricted Delivery ' Restricted Delivery
(-over s�nm
PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
_ J
USPS TRACKING#
First-Class Mail
r Postage&Fees Paid
USPS
3 ' Perms No.G-10
9590 9402 lkh b3 1784 84
United States •Sender:Please print your name,address,and ZIP+4®in this box•
Postal Service --
I
Town of Barnstable
Health Yivision
200 Main,Street
Hyannis, MA 02601
I
I I I
I
Barnstable
oFtT Town 'of Barnstable
�o Regulatory Services Department Ad-Amei9eaCCy, v
BARNSfABM
9� 6 MASS.q Public Health Division
�f0N1P�A 200 Main Street, Hyannis MA 02601 2007 I
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4988 0176
March 22, 2018
Perry, Leroy J Jr & Bonnie
134 Main Street
Cotuit, MA 02635
Dear Mr. and Ms. Perry,
On March 21, 2018, the Town of Barnstable Board of Health voted to eliminate Section
360-9.1 of the Town of Barnstable Code. This means septic system inspections no longer
fail based solely on the observations of the liquid levels inside leaching pits.
Recall that the septic system located at 134 Main Street, Cotuit, MA was inspected on
02/28/2018 by Michael DiBuono, certified Title V Septic Inspector for the State of
Massachusetts. The inspection of your septic system showed that the system had failed
based upon the liquid level in your leaching pit. However due to the elimination of this
particular provision, it is now suggested that you have your septic system evaluated again
in approximately six months to one year.
If you have any questions, please contact me at 508-862-4644.
Sincerely,
Thomas McKean,..S., CHO
Agent of the Board of Health
CC: Michael DiBuono
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\134 Main Street Cotuit.doc
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Main St.
Property Address
Leroy 8r Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
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.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S.M.Jones Title V Septic Inspection
r� Company Name
74 Beldan Ln.
Company Address
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com SI4522
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!!'nspecc Mn
was performed based on my training and experience in the proper function and maintenance ofron si€e'
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of=
-4.�
Title 5(310 CMR 15.000).The system:
Fo
® Passes []' Conditionally Passes , " '
❑ Fails I--
rn
❑ Needs Further Evaluation by the Local Approving Authority
4/5/2010
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies 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.
I
t5ms•09108 Title 5 Official Inspection Form:Subsurface Se4Dispoem-Page 1 of 17
,1
Commonwealth of Massachusetts
IEM
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Main St.
Property Address
Leroy& Bonnie Perry
Owner Owner's Name
information is required for every Cotuit _ Ma 02635 4/5/2010
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:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection I°orm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Main St.
Property Address
Leroy & Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a 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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface.Sewage Disposal.System Form-Not for Voluntary Assessments
134 Main St.
Property Address
Leroy&Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. CitylTown 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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
Tess 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 '/day flow
t5ins•09108 Title 5 Official fnspection 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
134 Main St.
Property Address
Leroy& Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Citylrown 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
❑ ❑ 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.
t5ins•09108 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
134 Main St.
Property Address
Leroy&Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Cityfrown 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?
Z ❑ Has the system received normal flows in the previous two week period?
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Main St.
Property Address
Leroy&Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): yes
Detail
2008=57,000 total gallons= 156 gpd 2009= 88,000 total gallons=241 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Main St.
Property Address
Leroy&Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Cityfrown 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: pumped 2008 per owner
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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
134 Main St.
Property Address
Leroy& Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
new system installed 9/24/1993 town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5feet
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.):
Joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade: .9
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 gallons
Sludge depth:
4"
t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
up
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Main St.
Property Address
Leroy&Bonnie Perry
Owner Owners Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness 211
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? Opened covers and took
measurements
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 does not need to be cleaned now but should be done every 2 years as maintenance. Outlet
baffle intact and in good condition. water level was at bottom of outlet invert, tank was structurally
sound and not leaking.
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•09/08 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
°t 134 Main St.
Property Address
Leroy& Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Main St.
Property Address
Leroy&Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Citylrown 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.):
Distribution box was found to be functioning as intended.Water was flowing freely from septic tank to
leach 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.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Forth: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
"t 134 Main St.
Property Address
Leroy& Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 6x6
❑ 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.):
At time of inspection the leach pit had 2'of available leaching with a stain line approx 2"higher. No
sign of past hydraulic failure, soil and stone surrounding pit was not saturated. No lush vegetation.
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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5.`y( 134 Main St.
Property Address
Leroy& Bonnie Perry
Owner Owner's Name
information is Cotuit Ma 02635 4/5/2010
required for every
page. Cityrrown 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.):
III
t5ins-09/08 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:
< 134 Main St
Property Address
Leroy& Bonnie Pent'
Owner Owner's Name
information is required for every Cotuit Ma . 02635 4/5/2010
page. Cityrrown 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
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t
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'
13- J y� T( q S-)i
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t5ins-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 134 Main St.
Property Address
Leroy& Bonnie Perry
Owner Owners Name
information is required for every Cotuit Ma 02635 4/5/2010
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:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour
map.Bottom of leach pit is 8.5' below grade.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 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
134 Main St.
Property Address
Leroy& Bonnie Perry
Owner Owner's Name
information is required for every Cotuit Ma 02635 4/5/2010
page. Cityfrown 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-09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
c TOWN OF BARNSTABLE
LOCATION SEWAGE
VILLAGEdi ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. �%_ /� J1�1/Q'ft�.�i'/"SSQ•�r
SEPTIC TANK CAPACITY /OQQ
LEACHING FACILITYAty (size) /000
NO. OF BEDROOMS- PRIVATE WELL OR .PUBLIC_WATER__ _
a
BUILDER OR OWNER
DATE PERMIT ISSUED:
G�
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�r� �. is
J ..�S�`
., � �,� �
.� - _`- �-
__ _ _ 2�
� n
_ is i ` �
�_ .4 �
:.x
No..l. 3."._h,_� Fps.....:�....30 .00
THE COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH . soAPPWaD
TOWN OF BARNSTABLE
Appliratiou for Dipaiial lVurk C�a�gt�tr r to DM 3
�i
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
134 Main Street Cotuit
..--•...............•-•---.........................------....------........--------•--------....-- ----------•-•-----------------..........----------------------------•-•---........---•-••-------•-
Location-Address or Lot No.
BonnieR oa e r s-------------------------------------------------------------- --------------------------------------------------------------------------------------------------
........ .... •--- ........
Ow ter Address
W J.P.Macomber Jr .
Installer Address
UType of Building Size Lot-.._-------_--------------Sq. feet
Dwelling-X No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ).
a Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
R: Septic Tank—Liquid capacity............gallons Length---------------- Width-.----.--------- Diameter.------.-.------ Depth................
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------------.............---........---.
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------------------------------•--------------------- ---•-•----...... ------------------------
.---------
0 Description of Soil.-----•-•..................•-•-••---....----•--------------------•-----•---•------------.-----------------------------------------------------•-•--...............---...
W Sand
V ---•......................•----------.....-----------------------------------------------.......----------------------------------------•----------------------•-•--••---•-•-----....-•-----•-••-------.
W
UNature of Repairs or Alterations—Answer when applicable.--.---------.1-10 0 0 ...11 on tank
1--distribut-ion_box.,-1.-1000__._qal_lon...leach wit . _
................L......._--_-••-•_-•-_...._--................_----......._._.._.........................
Agreement-.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce has b n ' sue by the bo d health.
Signed ... .. -..... ti.......................... .....8..1.3.�./..93.....:......
Dace
Application Approved B - .......................... .-.3..r..-. ..�.-
PP PP Y ....... -4'�"''-"''- Date g
Application Disapproved for the following reasons: ............................
............. ............................................................ .... ... .......... ...................................... .. .. .. ... ..................:........ ...................--.... ..
GG�� Dace
Permit No. ........L..5.........LY..��----------- Issued
Dace
No.. .'. /FEB......$............�.._.
30 00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirtttion fur Diripagal lVlarlui ( owitrurttnn rrm" t
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an,Individual Sewage Disposal
System at:
134 Main Street Cotuit
...-•-•--------------------------••--------•----•----.......---------------------------..._.....-- -------•-•----------------...................•--------•-.._......_..••-••........•••............•.
Location-Address or Lot No.
Bonnie Rowers
Owner Address
W J.P.Macomber Jr.
Installer Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling 4 No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
p' Other fixtures --------------------------------------- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity------------gallons . Length________________ Width................ Diameter................ Depth................
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........................................
a
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
fit Test, Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................`
9 t ....------•------------------•--•-------•-------------•--------------............--•---••---•------.....--•---•-••---•--••--•---•-•--...................---•-
0 Description of Soil.......................................................................................................................................................................
Sand
U --------------
•...........
....
..-----------------------
.------------------------
-------------------
•---------------------------------
•------
•------------
-----------------------------------------------------------------------------------------------------•----------------------•---•-.._....--•-•-
UNature of Repairs or Alterations—Answer when applicable--------------1-1000 gallon tarik
1-distribut_ion_ box, 1-1.000___gallon leach pit................................................................................
._..... _•,_..___..
Agreement: I -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees'not to place the
system in operation until a Certificate of Compliance has b en/issued by the board of health.
Signed ........ 40...... ..... 8/3.1/9-3.. .... - . .`�.....�.:......
Application Approved BY ----- ... .�.---------
e ,...
Application Disapproved for the following reasons: . .... ........... . ................................................................ .......
.............. ......................................................................... .... ............................. .....................................:.................. ........................................
��. Dace
PermitNo. ......../-.5----_.---- .�1 .:`D............... '"' ,. Issued .......-----..........................................-- ....
Dare
THE COMMONWEALTH OF MASSACHUSETT s
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gertifirate of Comylinure
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( XX
er J' )
J.P.Macombr
by ........................................................................... ----------------------.---..--- --------. ....er.....------.-----..------- -- -----------------------------------------.--------.-----------------------------------
rah
134 Main Street Cotuit
at ........... ..............._............------_------------------------ -------------------- ----------------.------------------------------------------........................................................................
has been installed in accordance with the provisions of TITI,E 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..........! :3�---L/. dated ._.........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. .
C
DATE................ _�... �.....-.f.. ...... - ---...-------------... Inspector ...... . ...:_....... .........._. . ...........
_-- ----------- ----_---_----.--_.---_------------ •------>------------------7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.....F�1. FEE.......--..3 0...0..
Riploal Vorb Tomitrudion lermit
J.P.Macomber Jr.
Permissionis hereby gran��ttXed------ ---------,-,,-----------------•-------.....----------------------------------•••-•-------------------•-..-------•--.....----.............
to Cons t uc� or 5tpreetX�'otuiftvirlual Sewage Disposal System
atNo........................................................................................................... ---------------•------------------------------------------------------.............
Street ec��
as shown on the application for Disposal Works Construction Permit No.,l3-.95.5_- Dated...........................................
----........................ •�� --•-------------------•---•--•-----••--
••-•--. ........... Board of Health
DATE �._
FORM 36508 HOBBS♦!WARREN.INC.,PUBLISHERS