HomeMy WebLinkAbout0450 MAIN STREET (COTUIT) - Health 450 MAIN STREET
COTUIT -- - - -- --- _ -- - -- - - - -- -
_- A = 022 - 015 y f
I
i
- Commonwealth of Massachusetts _ r
-- Title 5 Official Inspection Form
Fle Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-
�,� 450 Main St.
Property Address
Beverly Giartini
Owner Owner's Na e
information is �} ,
required for every Cotuit 1/ _ _ Ma. 02635 _ 5-1-21
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:
forms When
fillip out f A. Inspector Information
on the computer, _Michael Sears
use only the tab
key to move your Name of Inspector
cursor-do not Jim The Inspector Man
use the return — — — - -- -
key. Company Name _
P.O.Box 784
-- - _
Q Company Address
West Yarmouth Ma 02673
City/Town ,State — - . Zip Code
508-364-4398 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes `\��uuuuunuvi�i�
"jN OF 444 vie
2. ® Conditionally Passes .•
MICHAEL '•:m
3. ❑ Needs Further Evaluation by Local Approving Authority 'o: SEARS ;�
4 No.SI14430
4. ❑ Fails S 'r'cFRrtF�`��
- 5-1-21
Inspector's Signatur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c commonwealth of Massachusetts
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
450 Main St.
Property Address
Beverly Giartini
Owner Owner's Name -
information is required for every Cotuit Ma. 02635 5-1-21
page. Cltyfrown State Zip Code Date of Inspection
C. Inspection Summary,
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes: n
❑ 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:
D Box walls are gone and needs to be replaced
2) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
450 Main St.
U� Property Address
Beverly Giartini
Owner Owner's Name
information is required for every Cotuit Ma. 02635 5-1-21
-
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑' broken pipe(s) are replaced ❑ Y ❑ N ❑ 'ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑-ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment. ,
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
- Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
450 Main St.
,u Property Address
Beverly Giartim
Owner Owner's Name
information is Cotuit Ma. 02635 5-1-21
required for every - -- ---- - -
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria'indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
450 Main St.
`V Property Address
Beverly Giartini
Owner Owner's Name
information is Cotuit Ma. 02635 5-1-2.1
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
' R
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
450 Main St.
Property Address
Beverly Giartini
Owner Owner's Name
information is Cotuit Ma. 02635 5-1-21
required for every -- - -
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes 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 facilityor dwelling inspected for signs of sewage back u ?
9 p 9 9 P
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
450 Main St.
Property Address
Beverly Giartini
Owner Owner's Name
information is required for every Cotuit Ma. 02635 5-1-21
-
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to: -
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2019- 56000 gal
9 ( Y 9 (gp )) 2020-59000 gal
Detail:
Sump pump? ❑ Yes ® No
• _
Last date of occupancy: PresentDate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
./ 450 Main St.
Property Address
Beverly Giartini
Owner Owner's Name
information is Cotuit Ma. 02635 5-1-21
required for every - _- �- - -
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment: --
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: -- --- — -
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below) ,
3. Pumping Records:
Source of information: 2019
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: --
gallons
How was quantity pumped determined? -
Reason for pumping: . -
k i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
(Z Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
450 Main St.
Property Address
Beverly Giartini
Owner Owner's Name -
information is required Ma. 02635 5-1-21
required for every _ —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes-® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
y I
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
J� 450 Main St.
Property Address
Beverly Giartini _
Owner Owner's Name
information is Cotuit Ma. 02635 5-1-21
required for every —__ —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 20
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
1000 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
•Sludge depth: 2"
11,
Distance from top of sludge to bottom of outlet tee or baffle 28— - — --
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle -
12"
17
Distance from bottom of scum to bottom of outlet tee or baffle ---- —
How were dimensions determined? Sludge judge, tape, plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 gal tank with inlet tee and baffle out in place, inlet cover 20" below grade
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
.i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
450 Main St.
Property Address
Beverly Giartini
Owner Owner's Name
information is required for every Cotuit Ma. 02635 5-1-21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: — -
I
Scum thickness
Distance from top of scum to top of outlet tee or baffle -- -
Distance from bottom of scum to bottom of outlet tee or baffle ---
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: -
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
iSubsurface Sewage Disposal System Form Not for Voluntary Assessments
450 Main St.
Property Address
Beverly Giartini
Owner Owner's Name
information is Cotuit Ma. 02635 5-1-21
required for every _-___-_.__--. -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: -- - --- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
" Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.): ,
D Box is 16x16 with 1 outlet pipe, cover at 32" below grade
D Box walls are gone and needs to be replaced
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u—
450 Main St. T
Property Address
Beverl Giartini
Owner Owner's Name
information is Cotuit Ma. 02635 5-1-21
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
7
If SAS not located, explain why:
Type.
® leaching pits number:
1
❑ leaching chambers number:
a
❑ leaching galleries number:
❑ leaching trenches number, length: --
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: -- -
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
w
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
450 Main St.
Property Address
Beverly Giartini
Owner Owner's Name
information is Cotuit Ma. 02635 5-1-21
required for every -__
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is a 1000 gal pit, Pit is clean with 3'of standing water and no sign of failure
12. Cesspools (cesspool must be pumped a f'
p ( p p p s part o Inspection) (locate on site plan):
)
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer - —
Depth of scum layer --
Dimensions of cesspool
Materials of construction -- --
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
450 Main St. _
Property Address
Beverly Giartini
Owner Owner's Name
information is Cotult Ma. 02635 5-1-21
required for every ---- — --
page. City/Town State Zip Code Date of.lnspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: -
Dimensions - -- -- - --
Depth of solids -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Y
R
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
<Lx Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
450 Main St. -
"� Property Address
Beverly
ne
Owner Owr's Name
information is Ma. 02635 5-1-21req _
Cotuit _ _ _ ._ _
fired for eve — — -
pag every City/Town State Zip Code Date of Inspection
page.
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide.a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
e
2
A
q.8 t
L
y-
•oZ—�� � `��Ntunmll�u�i�
7J— ,�� �! o`•��p�-NN OF Mgss,���
S. \4� MICHAEL LP 9cy�5
0. SEARS •:
*: No.S114430 :co
i N S
t5insp.doc-rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
d Title 5 Official Inspection Form
IW
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
450 Main St.
Property Address
Beverly Giartini
Owner Owner's Name
information is Cotuit Ma. 02635 5-1-21
required for every -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
I
® Shallow wells
Estimated depth to high ground water: 15+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: pate
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Hand augered 4' below SAS with no sign of ground water
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
- t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
c Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
AI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
450 Main St. -
`" Property Address
Beverly Giartini
Owner Owner's Name
information is Cotuit Ma. _02635 5-1-21
required for every -- --
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector information: Complete all fields in this section.
® B. Certification:Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
l:�nJfic�m S 1',5
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
a
W?j
No. G I (b S Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application fo "sposal 6pstent (Construction Permit
Application for a Permit to Construct( ) Repair _')Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. er's N e,Address,an(h)el.No.
Assessor'sMap/Parcel
Insttaller's Name,�ddrgsgan .Tel.N "� Designer's Name,Address,and Tel.No.
c
Type of Building:
' 1
Dwelling No.of Bedrooms IV Lot Size cJ11;_)sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer whe ap licable)
P(.t f cR 6 Csw 1�� "vl
Date last inspected: ��tL $ -" J/
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 Cod and not top ce the system in operation until a Certificate of
Compliance has been issued by this Board of al Q.
Signed -t 4Date //d JJ
Application Approved by f \ Date Sr71-2
Application Disapproved by 6K Date
for the following reasons
Permit No. 9 f'(6 J Date Issued �?
------==-----------=s_a__ ----a----------------------- � +.. .
No.
G ! ( !s S Fee u z
THE COMMONWEALTH OF MASSACHUSETTS Entered in.computer: fes Ci
PUBLIC HEALTH DIVISION - TOWN OF,BARNSTABLE, MASSACHUSETTS
� 1b
ltlYltatIDIY fOC-..Disposa[,6pBtEm,tDTC'wurtion.3permit a
Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System " Individual Components
Location Address or Lot No. ' `O er's Name,A dress,andiTel.No. "
Assessor's Map/Parcel tf�.1 �,�" A4 9 i.., 1 V r J
Ins. lle 's Name, ddre'ss,an Tel.Now - Designer's Name,Address,and Tel.No.
Type of Building: i/ �j
Dwelling No.of Bedrooms tj b�✓1 O.Lof Size 014 4 ..)sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers.( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan 'Date Number of sheets 1 Revision Date
Title
Size of Septic Tank Type of;S.A.S.
Description of Soil i
J ,
0
r
Nature of Repairs o Alterations(Answer whe applicable) �.
��Ct"7 �i i •k� �*3 CC �3 '� �(,� . �� ,. rra7alq�
Date last inspected: Sa cl ..' ✓ �° .J `
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 Env}ronmental Cod@ and not top ace the system in operation until a Certificate of
Compliance has been issued by this Board of alth. \ >{
Signed �k - ::Date � .. °�� _ 7
- .:3 :
Application Approved by r 1 r 3 Date
Application Disapproved by all' Date
for the following reasons 4
Permit No. P( 6 Date Issued %/,7/
- r - - ------ - - -- -----
THE COMMONWEALTH'OF MASSACHUSETTS
BARNSTABLE,`MASSACHUSETTS.
Certificate of Compliance
THIS IS TO CERTIFY that the On-site Sewage Disposal system�Constructed,( ) Repaired( ) Upgraded
Abandoned( )by 1< ( v. ,
has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �' 44 1 dated
Installer Designer
#bedrooms �j Approved design flower / gpd
The issuance of this permit shall not be construed as a guarantee that the system will(function as designed.
Date / Inspectors .
No. �. a l b' Fee ��
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS
Bisposal 6pstrm Construction 'Permit
"permission is hereby granted,to Construct( ) +Repair( ) Upgrade( ) Abandon( )
System located at n
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three,years of the date of this permits
Date �'7 /� Approved by $ �'�
-rift
IK
13
�gip. �< •�
C)
-t-
2
iY
Q
A
i
alb �
t
r
d Ib''X
�.v F` S 5 4� � • - Y �f -
i
z4 rt53ox �5' 3�' btlo ,.��d�
?� ''A.,•-.� ,.ate �.� .�
Y
f
Town of Barnstable
KMA Wy�"B` r inspectional Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
l humas A McKean,CHO
C)rtice' 508-862-4644
FAX 508-790-6304 Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(1-own Code §360-44 and Title V: 310 CMR
An "x'' marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ 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 clogged SAS or cesspool
❑ Backup of sewage into the house due to an over
or
❑ Structurally unsound septic tank or SAS
ONE l YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool
❑ A portion of the SAS; cesspool, or privy is below the high groundwater elevation
❑ A portion of the cesspool is located within a Zone 1 to a public well
❑ portion of the cesspool is located within 50 feet of a private water supply well
A.p no acceptable water qu ality analysis. (This system passes if the water analysis
With indicates the well is free from pollution).
TWO 2 I YEAR DEADLINE CRITERIA
❑ Single Cesspool
o Any "conditionally passed systems" (broken cover; relocation of a pipe; relocation
of a driveway due to 1I-10 components; etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per gown
Code §360-20 h)
ER
7 —
Repair deadline:_—Lyj: � --
OASEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
[� �TOWN OF BARNSTABLE oar
LOCATION / �TlN 5 SEWAGE #
VILLAGE ASSESSOR'S MAP LOT
INSTALLER'S.NAME & PHONE NO. �VAJ
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS 3 PRIVATE WELL OR U�BLIC�WAT
OR OWNER
DATE PERMIT ISSUED: 7
DATE COMPLIANCE ISSUED: � D
VARIANCE GRANTED: Yes No
� �
� � ����
.. ,_ -.
� -
� L,-o
a
� � ��
O �
Y
TOWN OF BARNSTABLE O
LOCATION 104' AV ?) 571-G'e-r SEWAGE #
VILLAGE �/�®� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY AZ6 r/w
we
LEACHING FACILITY: (type) 1)( (size)
NO.OF BEDROOMS
BUILDER OR OWNER 7-
PERMTTDATE: COMPLIANCE DATE:
}
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility J Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) IV Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet f leachin fa c �, / Feet
Furnished by .v
r i
3
f
No.._J..D.:. ./ Fx$.. ? ._......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appli ation for Bhipasal Workii Tonstrurtiun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
----.... _-! �' S d �- '- -----------------------•----...... -•-•--•-•--•----•--•----•.....-------•-•--
.'Y J14 �L v ,v ocation:•Address j- NO-•................................•----... �I
W 1 v ,` Owner 0 V U i P Addre /j
M� t'f< — 3 r/ (. v...........................^ Ki .�..T-----------•-•--•--•...............
PQ Installer Address
UType of Building 3 Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Pk Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..•------------------------------------------- ------------------------
W Design Flow............................................gallons per person per-day. Total daily flow............................................gallons.
WSeptic Tank—Liquid ca.pacityl/-•gallons Length................ Width................ Diameter................ Depth....
Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------l_.......... Diameter-----Q_...._______ Depth below inlet______ ........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation 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_.....................
---•---•--------------------------------•----•-••-••-------------•--._....----------•----------............-------•-•--------•-...--------..__._...•---•-----
0 Description of Soil...............................................................................----•-----------•----------------•--•----------------------_______-_---------------•-••-
V ...............................................................=------------•--•-•••-•--•---------•-••------------••-------•_-•-----•---------•_••••-----------•----------------...•••••----•-----------
�:
UNature o Re airs or Alt ations—A wer when a ble_/-_ 2�_ _ __________-
et
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 Compliance has been ir�,i6
i by the board of health. /
' / -----",'_- / //,�_
Signed --------- w--� ------------ ------------------------------ --- lll... - --....
Application Approved By ........
Application Disapproved for the following reasons: .. .` ---- ---------------------------------------------------------------------------- ----------..............................
---------------------------------------------- ---- -- ----------------------------------------------- ---- -------------------------------------- ------------ ----------------- ---- ---------- ----------------------------------------
Date
PermitNo- ------............................................................. Issued ---.....................----------------------...................
Date
1
No.--Y Fizim 3<-�>.......
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Bispnuttl Warks Tunutrnrtion thrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( )) an Individual Sewage Disposal
System at:
A-��
i T �!�
ocation-Address or I.o No.
..... � �L(/N� 5 G 7—o 'tv l 7— , v�f
(L� v V 4_N W& �"�Owner V K � v/L C.e Addre��A ,/�
a ---------------------------------------------------------------------------•....._.._.......----- --------....................................v--1---.---'....------..................-•------
Installer Address
Type of Building 7
3 Size Lot----------------------------Sq. feet
U
a Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building --________-.•--------------- No. of persons............................ Showers ( ) — Cafeteria ( )
al Other fixtures -------------------------------- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity. 0_gallons Length................ Width-----------_--- Diameter................ Depth....3'_......
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........................................
aTest Pit No. 1________________minutes per inch Depth of Test Pit-------------------- Depth to ground water_____________-_--_•-_-_-
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------------------------------------------------------------------------------------------------•.........................................................
ODescription of Soil.............................................................................--.....-------------------------------•------------------------=----------------------•---
x
- ---------- --- --------- ---------------------��------------------------------------------------•----•------ = ......------
U Nature of,Repairs or Alterations—An wer when applicable_.Z04ell •�f_A _____ �..��✓�_..__.
-•--:�./��__�A� �� ���---------------------------------------------------------------------------
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 Compliance has been issued b' the board of health.
} Signed------------p ' ..N '7 1 /-a?,te �Uv - ----
Application Approved BY ----- V - ._ �, n.�..� ..-------- ---- ----- -------------- . ..-�-
Application Disapproved fo the following reasons: .....:.................... ----------------------------------------------------------------------------------------
---------------------------------7---------------...-----------.................................---------------...... -------- .........................................................---- .......................................
Date
Perm tJNo. -.- Issued ,---_......................
-------` ------------------------------- --- to
i Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifirate of Tomplittrue
THIS IDS`PTO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by lr .----------.' �11�� z�-
_ Installer
at ------------y -5....C>--------��� ........... —T-_-----------r' ��n t------------------------------------------------ -
has been installed in accordance with the provisions of TITLE 5 f,The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .......C*C-•-.-��. - ........ dated ------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEDD S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. j
15104/'
DATE ""� '� /.......- �..... Inspector:...... � f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
NO....
;1 FEE.... .
Disposal Workv T.unu#r iun rrutit
Permission is hereby granted.........../V-------- ------------------------------------------•-----•-•-------------.....---................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
--------............................................
treet
as shown on the application for Disposal Works Construction Permit �'�__ Dated..........................................
,) .................................=" \•_�---------------------------------------------------
U
-.--.-- '
DATE---•--------------�-'.��.----�----------------------.. Board of Health
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS