HomeMy WebLinkAbout0207 MAIN STREET (COTUIT) - Health 207 Main Street (Cotuit)
Cotuit F/R
- ---- - - - 023 002 - -- - - - - -
TOWN OF,BARNSTABLE �1
'ATION 07 41414 YZ SEWAGE # 1000
:AGE 6o7111f ASSESSOR'S MAP &LOT 023, 00�
INSTALLER'S NAME&PHONE NO. 525- 21017-117�/os�inh
SEPTIC TANK CAPACITY 4500
LEACHING FACEL=: (type) Z-cSOo (size) ' -ISJC/3
c'-NO.OF BEDROOMS
BUILDER OR OWNER Ml,.5 d7r
PERMIT DATE: 0-2 7-2 t COMPLIANCE DATE: -'R=3/-of
Separation Distance.Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells,ezist .
on site or within 200 feet of leaching facility) - Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �� G .
� h Y77,
33�
113
s/.
q l i
No. Q 1' �°� Fee U "
' THE COMMONWEALTH OF MASSA_►CHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for Migpozar *p5tem Con.5tructiou Permit
Application for a Permit to Construct(t,-1fRtepair( *Tupgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 107 *1,4!e S r Owner's Name,Address and Tel.No.
Assessor's Map/ParcelC Oral r
Installer's Name,Address,and Tel.No. 4,:20—9`l%fj' Designer's Name,Address and Tel.No.
✓o5ep,4 ®�3,4p-piar DAV/W Awosvv?
ly I !4 sr dfCeo
Type of Building: JD-�- �rI a?G#y .�� - �.,L , Ik :�'.
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1 161014 6iqly,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thi Boar of Health.
Signed Date
Application Approved by Date 'M&tv
Application Disapproved for a following reasons
Permit No. og o o t/—q S). Date Issued 2 0 L
---------------------------- - ------------�____
~ No. �1 J \. ti§ Fee /0 U
r t Entered in computer:
/THE 40MMONWEALTH OF MASS6,CHUSfi3T I S } Yes
PUBLIC:HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zlpprication. for"Mig;pbot *pgtem Congtruction Permit
Application for a Permit to Constrdct( fepair( -)'Upgrade( )Abandon( ) O Complete System ❑Individual Components
iV
Location Address or Lot No. Q p y `1 r¢!�! � 7" Owner's Name,Address and Tel.No.
Assessor's Map/Parcel G 0 rU 1 7- l9f'fl r!O t' Oh
t ..
Installer's Name,Address,and Tel.No. eo'ZO—Q7 S Designer's Name,Address and Tel.No. $..46_ 9 — 2/177
,1*5eP4 04v,�/`` se�
/ fsA ter✓TJ` � ,%/ m.Sr 5.v 04e 6
Type of Building: A.�• k�)7`oy ',n z qc , I kAr M.
Dwelling \ No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( )
Other ,Type of Building No.of Persons Showers( ) Cafeteria( ) �/
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date I �� Y ,,(f 'Number of sheets Revision Date
1.
Title v, ry
Size oi�Sepitic Tank l Type of S.A.S.
Descriptioin of Soil
)+ fS'
j 4- 1) -
Nature of Repairs or Alterations(Answer when applicable) zo 5TI411 ./S a B ,/,,4/ 5-"f-o►rze 7;o o '
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed tip- ' iJ111v / Date
Application Approved by Date V 7/I)L/
Application Disapproved for the following reasons
Permit No. o�o u U Ui Sa Date Issued
r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( 4►•-)Repaired( `-)Upgraded( )
Abandoned.(---)by
at o t�? ih i�: ['_ra i .ri T has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. o10 UV- q5 a dated 7/
Installer .fas�_�rJ /a1 gy,;_v*a.S Designer
The issuance of thlts pho ,
shall not be construed as a guarantee that the s t� wilfurnction as designed.
Date �i Inspector 17 t,\,. 42 11-
No. U —' y - Fee l oo
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, A ASSACHUSETTS
Mi5pogal 6pMem Congtructio � Permit
Permission is hereby granted to Construct(. 4)Repair( '~)Upgrade( )Abandon( )
System located at 29 07- XIAg►0 J i-,
r
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction Xnust be completed within three years-of the date of thi eft.
Date: 7 A) Approved by � .
d
TOWN OF BARNSTABLE
LOCATION, 107 494r4 ,SST SEWAGE # 1,000
VILLAGE (,o-f&i' ASSESSOR'S MAP &LOT 023. Ov2-
INSTALLER'S NAME&PHONE NO. 95- `122-
SEPTIC,TANK CAPACITY 1,500
op
LEACHING FACILITY: (type) 1- (size) /3
NO.OF BEDROOMS `
BUILDER OR OWNER 92
PERMITDATE: g-2 7-O y COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist .
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If anyewetlands exist
,within 300 feet of leaching facility) Feet
Furnished by— W=4 -;L�;ea�Y
W-fl;1 SST,
I
i
i
i
,9G
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Town of Barnstable
tHE Tgwy Regulatory Services
yam? �•P
Thomas F.Geiler,Director
' snxxsrAsr.&
Public R.ealth Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date:
Designer:: • ���� �� Installer: oS-�/oli d� L�te��GS
Address: . Lw:tLeo - Address:
On was issued a permit to install a
(date) (installer)
septic system at n a design drawn by
1 (address)
1 dated A
(designer)
;?,certify that the septic system referenced above was installed substantially according to
,the design, which may include minor approved-changes such as lateral relocation of the
distribution box and/or septic tank.
y` I certify that the septic system referenced above was installed with major changes (i.e•
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State &Local Regulations. Plan revision or
certified as-built by designer to follow.
staller's Signature) * DAVO " ty
� r,. x• �i.
IAA '
(Designers ignature) (Affix Designer 't p`Here)
PLEASE RETURN TO, BARNSTABLE PUBLIC HEALTH DMSION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND,A,S-
BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
FAILED INSPECTION
q.
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d
DEPARTMENT OF ENVIRONMENTAL PROTECTION
d MAP OZ� R GEI�►�ED
JO, �'ARCE� ; ®®'� JUL 2 9 2004
s LOX ;
9
TOWN;OF BARNSTABLE
TITLES HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM'
PART A
CERTIFICATION
Property Address: 207 MAIN STREET COTUIT,MA 02635
Owner's Name: C/O BELL ONE REAL ESTATE LC* �Z
Owner's Address: 5 MAIN STREET COTUIT,MA 02635
Date of Inspection: 7/5/04
Name Df Inspector: (please print) JOHN GRACI,INC. =
Company Name: SEPTIC INSPECTIONS l :
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 CD
N
co >
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT --
I certif y that I have personally inspected the sewage disposal system at this address and that the informatio reported�elo Cos
true;a curate and complete as of the time of the inspection. The inspection was performed based on my tr,ining anZH rn
experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP appro ed system
inspector pursuant to Section 15.340 of ' 5(310 CMR 15.000). The system:
TitTit
_ Passes
_ Conditionally 1� s ' s
_ Needs Further v,luation by the Local Approving Authority
X Fails 1
Inspector's Signature: ', Date: 7/5/04
t
The system inspector shall submit a cop f this inspection report to the Approving Authority(Board of Health or DEP)within
30 daysof completing this inspection. I e system is a shared:system or has a design flow of 10,000 gpd or greater,the
inspec or and the system owner shall sub it the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
_ Notes and Comments
SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN SAS IS UP TO PIPE. THE OVERFLOW IS PAST THE
M EFFE TIVE DEPTH OF LEACHING.
****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.
Titla. Tnenantinn Pnrm 6/1 5 M00 1
Page of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prope ty Address: 207 MAIN STREET COTUIT,MA 02635
Owne : C/O BELL ONE REAL ESTATE
Date c f Inspection: 7/5/04
Inspe tion Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I ha a not found any information which indicates-that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 5.304 exist.Any failure criteria not evaluated are indicated below.
Comn ents:
SYST M FAILED TITLE V INSPECTION.LIQUID LEVEL IN SAS IS UP TO PIPE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain.
n/a Tf e septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits '
substa itial 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 th tank is less than 20 years old is available.
ND eN plain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipes .or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Heald):
_ broken pipe(s)are replaced
_ obstruction is removed
distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
_obstruction is removed
ND a plain: n/a
Page of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Prope ty Address: 207 MAIN STREET COTUIT,MA 02635
Owner: C/O BELL ONE REAL ESTATE
Date cf Inspection: 7/5/04
C. f urther 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
proteci public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and.soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well".Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
Pagez of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 207 MAIN STREET COTUIT,MA 02635
Owner: C/O BELL ONE REAL ESTATE
Date c f Inspection: 7/5/04
D. System Failure Criteria applicable to all systems:
You ji iW indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
YES (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in
310 C AR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necesE ary 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.
You must indicate either"yes"or"no"to each of the following:
(The ffillowing criteria apply to large systems in addition to the criteria above)
yes io
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
_ K 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.
a II
Page 5 of 11
t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 207 MAIN STREET COTUIT,MA 02635
Owne : C/O BELL ONE REAL ESTATE
Date of Inspection: 7/5/04
1
Check if the following have been done.You must indicate "yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ K Were any of the system components pumped out in the previous two weeks
X _ 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?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage backup? r
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the
baffle or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information_ on the proper maintenance
of sub urface sewage disposal systems
he size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is '
unacc(ptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Prop ty Address: 207 MAIN STREET COTUIT,MA 02635
Owner: C/O BELL ONE REAL ESTATE
Date f Inspection: 7/5/04
FLOW CONDITIONS
RESI ENTIAL
Numb r of bedrooms(design):2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Numb r of current residents: 1
Does gesidence have a garbage grinder(yes or no):NO
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO ��� ��`
Water meter readings,if available last 2 ears usage d y^ ;o: Y V
( Y g (gP ))sue-
Sump pump(yes or no):NO
Last d to of occupancy: n/a29
COM ERCIALANDUSTRIAL
Type of establishment: n/a
Desigh flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no):NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Sourc of information: n/a
Wass itstern pumped as part of the inspection(yes or no):NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reaso i for pumping: n/a
TYPE OF SYSTEM
_Sep is tank,distribution box,soil absorption system
X Single cesspool
X Ovc rflow cesspool
_Pri
_Shay ed system(yes or no)(if yes,attach prev�us inspection records,if any)
_Inn vative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
syste owner)
_Tigl it tank Attach a copy of the DEP approval
Other(describe): n/a
4 Appr ximate age of all components,date installed(if known)and source of information:
APP OX. 1950 PER AGENT/NEW PIT IN 81 ASBUILT
Were ;ewage odors detected when arriving at the site(yes or no): NO
Page of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 207 MAIN STREET COTUIT,MA 02635
Owne : C/O BELL ONE REAL ESTATE
Date of Inspection: 7/5/04
BUIL ING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:_cast iron _40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Conur.ents(on condition of joints,venting,evidence of leakage, etc.):
TOW WATER
SEPT C TANK: (locate on site plan)
Depth below grade: 0"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If t is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate)
Dimer sions: n/a
Sludge depth: n/a `
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum hickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How Nvere dimensions determined: n/a
Conur ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
GREASE TRAP:_(locate on site plan)
J
Depth below grade: n/a
Mater al of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dime sions: n/a
Scumthickness: n/a
Distar ce from top of scum to top of outlet tee or baffle: n/a
Distar ce from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Conm tents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to out et invert,evidence of leakage,etc.):
n/a
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 207 MAIN STREET COTUIT,MA 02635
Owner: C/O BELL ONE REAL ESTATE
Date f Inspection: 7/5/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Matey al of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dime sions: n/a
Capacity: n/a gallons
Desig Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order(yes or no):NO
Date c f last pumping: n/a
Comn ents(condition of alarm and float switches,etc.):
n/a
DIST IBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
Conur ents(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.):
NON
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 207 MAIN STREET COTUIT,MA 02635
Owner: C/O BELL ONE REAL ESTATE
Date of Inspection: 7/5/04
SOIL BSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Co nts(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
LIQU D LEVEL IN LEACH PIT IS FULL UP TO PIPE.PIPE COMES IN T LOWER THAN NORMAL.THE PIT
HAS r fO EFFECTIVE LEACHING LEFT AND IS IN HYDRAULIC FAILURE.
CESS OOLS: X(cesspool must be pumped as part of inspection)(locate on site plan)
Numb r and configuration: I
Depth top of liquid to inlet invert: 6"
Depth of solids layer:3"
Depth of scum layer: n/a
Dimensions of cesspool: 6'X5"'
Materials of construction: BLOCK
Indica ion of groundwater inflow(yes or no):NO
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
SYSTEM FAILS-THE OVERFLOW WAS FULL UP TO THE PIPE AT THE TIME OF THE INSPECTION-THE
PIT I PAST THE EFFECTIVE DEPTH OF LEACHING.
PRIV (locate on site plan)
Mater als of construction: n/a "
Dime sions: n/a
Depth of solids: n/a
Conur.ents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prope ty Address: 207 MAIN STREET COTUIT,MA 02635
Owner: C/O BELL ONE REAL ESTATE
Date of Inspection: 7/5/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet.Locate where public water supply enters the building.
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Page I 1 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 207 MAIN STREET COTUIT,MA 02635
Owne : C/O BELL ONE REAL ESTATE
Date of Inspection: 7/5/04
SITE ?,XAM J
_Slop
_Surface water
_Chec k cellar
Shal ow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
q
TOWN OF BARNSTABLE
�u 7
LOCATION � tE�; �f SEWAGE
VILLAGE L .� ��-- ASSESSOR'S MAP & LOT ��j,3• ,!.Z
INSTALLER'S NAME & PHONE NO. jk:-;;.�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) � �-7�� (size) � "�C 7
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER TG'
BUILDER OR OWNER )t� CLye;i jc i/o/,o
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: z-�
VARIANCE GRANTED: Yes No )(
��� � � `
�'� �
�a` , �
IA CAT ION SEGJAGE PERC3IT p0•
VilLADE
I N S T A LLER'S NAME D , ADDRESS
Poo I Meru c c
tBUIL.DER OR OW__ NES,
DA T E PERMIT ISSUED
DAT E COMPLIANCE ISSUED
H i O -k9,tA—
w,
510,
Q
cuss pool
I. P
4e y
Fms........$...5100....
THE COMMONWEALTH.OF MASSACHUSETTS
BOAR® OF HEALTH
.....................T own.........O OF
----------------------------------------------------------------
Appliration for Disposal Works Tonstrnrtinn Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
207 Main St. , C otut, MA 02635
................_....---_----.._.....----•---....------......-----------•-•--•.........__--_... .....•-•••--•-•-----•---...___.....••------•-•---••••-------•----......_...._•-------...--••--•---
Ellen M cock Location-Address or N
y 30 School St. , C otuit CIA 02635
W A & B Cesspool Servic ----
Owner 128 Bishops Terrace,ddyannis, 1�A 02601
---•------•-----...-•---•..............................•--••••--•-•-•-- •••...._..........•-••----.....-••--..........•--•...--•--....._._........................-•--•--•
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms................___._..._......._...--..-_..Expansyn Attic ( ) Garbage Grinder ( )
Other—T e of Building ..... No. of persons............................ Showers
a YP g --------•----------•--- P ( ) — Cafeteria ( )
Otherfixtures ----------------------------------------------------------------=---------------------------------------•-•---....--------------•---------...---------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
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...........>............................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -------------•-•------------------••--._....----..._•---------------......------•---•-•••---•_-•-_-•.........................................................
0 Description of Soil---Sand...........................................•-•------•------------------------------------------------•-------------------------------------._.....•-••_----
x
UI..................•----•........-------•••-•---•---------------------------------••-----------------------•---------•---•---------------•--•-•----------•--•-----------•-----------•--....---------•--•.
w
UNature of Repairs or Alterations—Answer when applicable._1a5tallat on...Qf..a...L M..gaal on-_-pre--cast.,
s 9 e__Pao lod._.1Qacti__p ...(.oxerf1Qw)-*------•--•........... ................ ------------------.....---•--------
-------------------------------------------- ---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITM 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the bo rd of health..
SignedA. -- ---------------- ......9117/_81.......
:
Da
Application Approved BY � �,1 !.....��--- --- -----------•.....- �117 f 81
Date
Application Disapproved for the following reasons-----------------------------•----------------------------------------- --------...--------------._......-•---••-
.....•-•........................................•••--------.....•--------•-•---•---------•-•--------•--•-----------------•---•-------------------------•----------------------------------------•-------
Date
Permit No......81-............................... /
-... Issued 9`•17.81...-•-------•-----------
Date
No..8lt-._$*S.Y.. F>n$........$....5,.00....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town.........0 F...............P:arn sta ble
Alip iratiou for Dtspoii al Works Tonstruriion anti#
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
207..Main St .,. Cotu&,t-M6 .........•: . ......_.... .........
-••-----•--•....................................................................•....._
Location Address or Lot No.
Ellen Piyc°ck........................•--•--....---•-•-•--•-........._......---.---•- 0 School St..:..Cotuitc.. !A....02635....---•---•-- - ......................
Owner Address
aA & PCesspool--Service................................................ 128 FAshops Terrace Hya nnis, NA 02601
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.............2............_.......__......Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons_..3...................... Showers ( ) — Cafeteria ( )
dOther fixtures -------••---------------•------------------•----------.-•---------------------------------•-------•-----------•--------.....-----.._......---------•--
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ---------------------------------------------------•--••---------...--------•---........-•-------•--.........................................................
0 Description of Soil---Sand...........................................................................................................................................................
U -------•------•---------------------------------•--••-••-•-•----•----------••----••--------•------•---•....--------------•----•-••------------------...................................................
W
---------------------------------------------------------------------------------------------------------------------------------------------------•---------------------...---------•-......-•--------
U Nature of Repairs or Alterations—Answer when applicable..installati-an...of.._a..1,000..gallon..pxe.-cajat.,
stane..P&ckeA._lea&ah..Pit... avarnav). ...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of_health.
Signedz!Ll�r��-�. .<.--- ------ ----- ` Jc?ti 91�71 1----------
y� Datp
Application Approved By....... �1 !............./ --- -- --------------------- 91171_.�1..........
Date
Application Disapproved for the following reasons:........-.....................................................................................................
_
....... ..... ..... ........••--••---------•--.....•-------••-•--•----•••--•--
Date
Permit No......81.-_____-___
..._..._.. Issued---------------9.17 21
.....--•--------•---•- -•--•----.......-•------..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................`.4wn............OF.......... ArnStaX.0..............................---................
Tntif iratr of Tontplianrle
THIS IS TO CERTIFY That the Individual Sewage Disposal System construessed ( or e •ired (X )
by A & B Cesspool Service, 128 TishoPs Terrace, Hyannis; MA 02601 - '�75 2
• . •------------------•---------•......------.
Instal
at....207 ?fain St., Cotuit, YA 02635 - Ellen l_ycock
•-•---------------------------------•-----------•-------•--------•••---------••-----
has been installed in accordance with the provisions of TIT4f 5 of The State Sanitary Code as scr)'ked in the
application for Disposal Works Construction Permit No.._..."�-.-_.____._ ..
.S5`r dated 9��7/---1
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....91�7�R1...............•---•----•----....----•------••-------•---. Inspector...................... ........................... \
THE COMMONWEALTH OF MASSACHUSETTS \�
BOARD OF HEALTH
. e ,
Town Barnstable
..........................................OF............ ................................_..................................... FEE....$..:5.-00..... ft\.
N o......81-....,'�.
�i��o��al urk� �on�irttr�iun rrntii ��
Permission is hereby granted..........A.& B Cesspool Service
...-•-----•-------•---•-------------••--•---•-•
to Construct ( ) or Repair (X) an Indivi ual Sewa e Dis osal System \
at No..207.Main St. ,, CotiAt�-MA 02635 Eden I;ycock
-----------•----...--•-
Street
as shown on the application for Disposal Works Construction Permit No.�1-............. D ed. ....__9/1��...:_......_._._....
Health
DATE9/17/9 Bo of...................•-••-----------•----...............
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS , \
ASSESSORS MAP : 40
O?j --
TEST HOLE LOGS
PARCEL:,
ILI( NOTES:
SOIL EVALU� TOR: I 1 � IM i
FLOOD ZONE: �I61; qq
_ - - WITNESS :
W61" ll� 1C.
1 1�
REFERENCE - 117'
DATE: 1) The installation shall comply with Title V and'mown of Barnstable Board of
0 PERCOLATION RATE'- / , is Health Regulations.
�✓ , ; �, �+� + 2) The installer shall verify the location of utilities, sewer inverts and septic i
L
components prior to installation.
TH- I TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot.
4) This plan is not to be utilized for property line determination nor any other
►� Z purpose other than the proposed system installation.
i
5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over H10 septic components.
IV
LOCATION MAP �,�?��� 7) The property is bounded by property corners and property lines as depicted.
64t, MO / 1 8) The property owner shall review design considerations to approve of total
number of bedrooms to,be considered for design. Receipt of a
g p payment for the
plan and installation based on the plan shall be deemed approval of the
\ number of bedrooms.
9) The existing cesspools shall be pumped and backfilled per Title V
Abandonrrient Procedures.
? -✓ 10)Proposed leaching is to be within 36 inches of grade or provide venting or cut
grade as permitted by the Board of Health.
1 11)System components to be 10 feet from water line.
t s . 12)Septic tank-to be a-minimum'of 1000 gallons.- If�tank is less than,1000 gal.,
i
SEPT I C SYSTEM' )E S I G N then replace with 1500GST.
FLOW ESTIMATE
�J BEDROOMS 'AT ( ID GAL/DAY/BEDROOM GAUDAY
i
�Z �rP,IL r�
1� Zvi I �< � � 2 �
A Tl fiARR - r
�J GAL/DAY x L DAYS
USE 14�ALLON SEPTIC TANK 7
O r' ����
(x.+J tq(LL
1 Va 6T' C�7
SOIL ALB �O"'' SYSTEM
_
SIDE AREA: 7,x . I Bp,+ n 2X .� = Ib9 -Z f }
�q 80TTOM AREA:
` '' 0°�t �,
PTIC SYSTEM SECTION 60t-6)�
r,
.01
y _
M
.. . __ IDPA
y 12�aw1 1h�N(
W
GAL,,,.
u.. ,I�; -mot
SEPTIC TANK l,►�Y�i.W
r
- -
�t O
ZY
F
00
6,TTV IJ� b� "1Y� 11 i '6 I ADO
SITE . AND . SEWAGE PLAN
LOCATION .
Cai7)� JAI J4
r
PREPARED FOR : ` � aTVV�
- i
° SCALE:
DAV I D MASON,JZS : DATE: 8
DBC ENVIRONMENTAL DESIGNS
EAST SANDWICH . MA
DATE HEALTH AGENT 508 833- 2177