HomeMy WebLinkAbout0523 MAIN STREET (COTUIT) - Health l
523 MAIN 51Ii GCS
- -- A 021 095
I
TOWN OF BARNSTABLE
LOCATION 523 175i41"l) 5�4 • SEWAGE #
VILLAGE � ASSESSOR'S MAP & LOT
INS T P T L ER'S NAME&PHONE NO.\ 9-%SOP) e ?Q
SEPTIC TANK CAPACITY ,/!5
LEACHING FACILITY: (type) 41 AZO
NO. OF BEDROOMS 3
BTUILDER OR OWNER
Y PERMIT DATE: COMPLIANCE DATE: f .3 " 0
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 any wetlands exist
within 300 fee f leaching facility) Feet
Furnished by
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No. Moo!7050 Fee 1/�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for �Digool *pztem Contr coon Vertnit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. U Owner's Name,Address and Tel.No.
Assessor's Map/Parcel �ew
Installer's Name,Address,and Tel.No. y� Designer' ame,Address and Tel.No. �rl _
6 f-0(-�-e f�i4�0?-,A- -F4., -G 7 7
Type of Building: RCi��S
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 25 T gallons per day. Calculated daily flow gallons.
Plan Date 1,5160 Number of sheets Revision Date
Title
Size of Septic Tank 156D Type of S.A.S.
Description of Soil
Ar-
Nature of Repairs or Alterations(Answer when applicable)
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 45a. oJo Date 2-
Application Approved by Date
Application Disapproved for a following reasons
got PMM-/
Permit No. - Date Issued
Fe
Na e 1D "d
00� 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
"PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
4.
01pprica.tion for Migogar *pztem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ;CompleteSystem ❑Individual Components
Location Address or Lot No. r Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer' ame,Address and Tel.No. Ll1 n
(xeo�yeFl�oz.a- y4-4-- 4�'63-�
Type of Building: y�RCit�s
Dwelling No.of Bedrooms_3 Lot Size • sq.ft. Garbage Grinder( )
Other , Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow _73�5 7,' gallons per day. Calculated daily flow gallons.
Plan Date /IZZ 5& Number of sheets Revision Date
Title
Size of Septic Tank /560 Type-of S.A.S.
Description of Soil: !
,:.
i 4" ' o
Nature of Repairs or Alterations(Answer when applicable) i {
P
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 Bo/1 of Health.
Signed l'c .dd e, Date 1 .Z"
g p
Application Approved by tiC ' Date
Application Disapproved for a following reasons it
Permit No. Date Issued
————————————————————————————THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CER �thate Qn-s' a Sew ge Di o al System onstru_.Jed( aired( )Upgraded( )
Abandoned( )by
at has bepn constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N902270,T44%ated
Installer Designer i
The issuance o f t s p frail shall not be construed as a guarantee that the sy to r ill fu ct'on desi 6 19
Date Inspector r zt� r J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mizpozal *pgtem Conotruc ton Permit
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this t.
Date: /3�/G%�D Approved by ( , ,. .
TOWN OF BARNSTABLE
LOCATION S23 /'hA-%n -r4 • SEWAGE # D'
vi
' VILLAGE � ASSESSOR'S MAP U� LOTAd
, INSTALLERS NAME&:PHONE N0.��4S�n 1-5OP)
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) y (size)
NO. OF BEDROOMS -3
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: .3
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 any wetlands exist
within 300 fee f leaching facility) Feet
• i
Furnished by
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Jun 07 2019 06:57 HP Fax page 19
aa1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
Property Address -
Carey Grover
Owner
Owners Na a ts�t
information is
required for every COtuit MA 02635 6-5-19t
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.
`p01gq�OF 1�rrIf�iq
Important:When ��
�
filling out forms
A. Inspector Information of (a8(_w 9�
--
on the computer, �: JAMES :rn
use only the tab James D.Sears =a:; ;
key to move your Name of Inspector c) P1 .6
cursor do not Ca ewide Enterprises c+ o;•'�
use the return
Company Name —
key. 153 Commercial Street lF S•iNSIP
—ICI NfrlHmi:nlltN
� Company Address
Mashpee MA 02649
City/Town State Zip Code
n + 508-477-8877 S1623
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
2. ❑ Conditionally Passes:
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
6-6-19
pector'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 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.
tsinsp.doc-rev.7/26/2018 Title 5 O'8rial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 16
s
Jun 07 2019 06:57 HP Fax page 20
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
v Property Address
Carey Grover
Owner owners Name
information is Cotuit
required for everyMA 02635 6-5-19
page. Cityffown 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:
® 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:
a
The system is a 1500 Gal, Tank D Box and four chambers
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):
151nsp.doc•ray.7126/2018 Tide 5 Official Inspecbort Fora,:Subsurface Sewage Disposal System•Page 2 of 18
Jun 07 2019 06:58 HP Fax page 21
Commonwealth of Massachusetts
_ lip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
.� 523 Main Street
Property Address
Carey Grover
Owner Owners Name
infreq wui red f is
for every
Cotult
red Fo MA 02635 6-5-19
page. City)Town State Zip Code Date of Inspectlan
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 ❑ NO (Explain below):
❑ . obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 ❑ NO (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,7128/2018, 'Title 5 Offidal Inspection Form:Subaurface Sewage Disposal System•Page 3 of 18
Jun 07 2019 06:58 HP Fax page 22
L� Commonwealth of Massachusetts
Title 5 Official Inspection Form
} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` p 523 Main Street
Property Address
Carey Grover
Owner Owners Name
information Is
required for every Cotuit MA 02635 6-5-19
page. CltylTown 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 feel 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:
I
a
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yeas"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.7128l2018 Title 5 official Inspection Form:Subsurface Sewage oiaposal System•Page4 of 15
Jun 07 2019 06:58 HP Fax page 23
Commonwealth of Massachusetts
- P Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
Property Address
Carey Grover
Owner Owner's Name
information is required for every Cotuit MA 02635 6-5-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant.) - -
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 is less than 6"below invert or available volume is less
than 1/2 day flow Ac/S�iv�
® 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 fai s. 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 C4.
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
1he.system is located in a nitrogen sensitive area (interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
15insP.doc•rev.7/2612018 mile 5 Ofriclal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Jun 07 2019 06:59 HP Fax page 24
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
P 523 Main Street
Property Address
Carey Grover
Owner Owner's Name
information is required for every Cotuit MA 02635 6 5-19
page City/Town 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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
® ❑ ' Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions, depth of liquid,depth of sludge and depth of scum?
El Was the facility owner(and occupants if different from owner)provided with
® informatio.n.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))
' r
15insp.doc-rev.i/26f2018 Title 5 Ofkial Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Jun 07 2019 06:59 HP Fax page 25
Commonwealth of Massachusetts
:. p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
• �J` 523 Main Street
Property Address
Carey Grover
Owner Owners Name a
information Is required for every Cotuit MA 02635 6-5-19 -
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 CM 15,203 (for example: 110 gpd x#of bedrooms): 330
Description:
1500 Gal.Tank D Box and four chambers.
Number of current residents: 0
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
Seasonaluse?
.. ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 2017-98,000Gals
2018-102,000Gal's
Detail:
Sump pump?
• ❑ Yes ® No
Last date of occupancy: NA
Date
15inaD.doc•rev.7126f2018 Title 5 Official Inspection Farr:SubsuKaca Sewage Disposal System•Page 7 of 16
Jun 07 2019 06:59 HP Fax page 26
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
Property Address
Carey Grover
Owner Owners Name
information is
required for every Cotuit MA 02635 6-5-19
page. City/Town State Zip Corte 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(seatslpersons/sq.ft., etc.):
A
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: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped;
gallons
How was quantity pumped determined?
Reason for pumping:
15insp.tloc rev.7/26/2018 Tise 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Jun 07 2019 07:00 HP Fax page 27
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
Property Address
Carey Grover
Owner Owners Name
information is required for every Cotuit MA 02635 6-5-19
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:
2000 Permit #2000 056.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2
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.):
Pipeing is 4" PVC &Cast Iron.
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
L
Jun 07 2019 07,00 HP Fax page 28
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
p� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
Property Address
Carey Grover
Owner Owners Name
information is
required for every Cotuit MA • 02635 6-5-19
page. CitylTown State Zip Code Date of Inspection
D. System Information (cant.)
6. Septic Tank(locate on site plan):
Depth below grade: 141
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: 1500 Gal. Precast H-10
Sludge depth;
Distance from top of sludge to bottom of outlet tee or baffle 29" '
Scum thickness On
Distance from top of Scum to top of outlet tee or baffle —8„
Distance from bottom of scum to bottom of outlet tee or baffle 1811
How were dimensions determined? Asbuift- Tape
Sludge Judge
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 at working level.Tank and covers at 14"below grade.ln and outlet tee's. No sign of leakage
or over loading,
t5insp.doc-rev.7/2 512 0 1 8 Tfde 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18
Jun 07 2019 07:00 HP Fax page 29
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
`f Property Address
Carey Grover
Owner Owner's Name
information is Cotuit MA 02635 6-5-19
required for every
page City/Town 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:
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 n ❑ polyethylene ❑ other(explain):
c
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/2612018 Title 5 Official Inspecdon Form:Subsurface Sewage olsposal System-Page 11 of 18
Jun 07 2019 07:01 HP Fax page 30
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
Property Address
Carey Grover
Owner Owners Name
information is required for every COtUIt MA 02635 6-5-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
B. 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 16"x16"-20"below grade Box is clean and solid w/two line's out. No sign of over loading
or solid carry over.
t5lnsp.doc rev.7r2e/2018 Title 5 Official Inspection Form:Sth5Urf2Ce Sewage Disposal System Page 12 of 18
Jun 07 2019 07:01 HP Fax page 31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F ,
523 Main Street
Property Address
Carey Grover
Owner Owner's Name
information is
required for every Cotuit MA 02635 6-5-19
page. City/Town State Zlp 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):
If SAS not located, explain why:
5-
Type:
❑ leaching pits _ number:
® leaching chambers number:
4
❑ 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(25l2010 Title 5 Oficiel Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
i—
Jun 07 2019 07:01 HP Fax page 32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
~ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
Property Address
Carey Grover
Owner Owner's Name
information is required for every Cotuit MA 02635 6-5-19
page. City/7own State Zip Code Date of Inspection
D. System Information(cant.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four infiltrators. Ck D Box prob area and camera out lines. No sign of over loading or
solid carry over. No sign of holiding water.
12. 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
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.);
151nsp.dac•rev.712612018 r Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 18
Jun 07 2019 07:01 HP Fax page 33
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
523 Main Street
Property Address
Carey Grover
Owner Owner's Name
information is
required forevery Cotult MA 02635 6-5-19
page. City/Town State Zip Code Date of Inspection
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.):
1
t5lnsp.dcc•rev.712 512 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Jun 07 2019 07:01 HP Fax page 34
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
523 Main Street
Property Address
Carey Grover
Owner Owner's Name
information is required for every Cotuit MA. 02635 6-5-19
page. City/Town State Zip Code Date of Inspection
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,
Kl o �3
► a �
,AI .3- 15 -5
19 rl s
317
>
t5lnsp.doc•rev,712612018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
I
Jun 07 2019 07:01 HP Fax page 35
c. Commonwealth of Massachusetts
Title 5 Official Inspection Form
rr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r5
523 Main Street
Property Address
Carey Grover
owner Owner's Name
information is required for every Cotuit MA 02635 6-5.19
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont,)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ ,Check cellar
❑ Shallow wells
NQ 10'
Estimated depth toFiigh ground water: 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:
Auger T.H.10' no G.W..Bottom of chamber's at 4'below grade. Bottom of chamber's at G above T.H.
Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Wnsp.dcc-rev.712612018 Title 5 Official Inspection Forth:Subsudace Sewage Disposal System-Pape 17 of 18
Jun 07 2019 07:02 HP Fax page 36
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
523 Main Street
Property Aedress
Carey Grover
Owner Owner's Name
inform
requir anon is
required for every Cotuit MA 02635 6-5-19
page. Cityfrown 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
to
G.w,
wnsp.doc-rev.A251201 B Title 5 Official Inspeclion Form:Subsurface Sewage CIS Mel Syslem•Page IS 7t 18
1 '
L0CAT101 SEWAGE PERIRIT NO.
-L'
VILLAGE
MSIT LL R'S a ADDRESS
' 3 OR OWNER
�-2 ; -
0A, TE PERMIT ISSUED
. DATE co-mPt. 1ANCE ISSULD ��� ` �3
V/l A4
- N� ..
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No...... ..................
7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1Z
.................... .....................OF........................................._.............
Appliration for Dhipasal Workii Towitrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
.................. ........................................................................... .................................................................................................
L tion- s or Lot No.
....... .. ... ....................................... .................... ........ ------------------------- ............."
4:— 0 e &dd�ross �
........ . .................. . .... .................................
. ......... ........ .... ....... ...........
Installer Address
Type of Building Size Lot_2�Z&6..e.....'00
..... ..........Sq. feet
Dwelling No. of Bedrooms............................................Expansion Attic Garbage Grinder (
Other—Type of Building ............................ No. of persons--------------_----------- Showers Cafeteria (
PL4Other fixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow...........1_.............................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length________________ Width----------------- Diameter_____.__--__-_:_ Depth......__....._..
W x Disposal Trench—No..................... Width...__.............__ Total Length........__.._.::._._ Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter............___._._. Depth below inlet.................... Total leaching area..................sq. f t.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.___........_._...._.__.
Li, Test Pit No. 2................minutes per inch Depth of Test Pit__..._.._......._._. Depth to ground water._:__..___..__.....____.
P4 11 4--------0.................................................................................................................................
0 Description of Soil......&1_1_1)-.'= ...... I................................I.................................................................................................
44 "�111 1'011"
U ........................................................................................................................................................................................................
.......................... -------------------------------------------------------------------.................;---------U----- ............ 4;.............
Nature of Repai;;s.�It.erati.ons—AQswer when appliqtble ... .. ...... .........................
ble._�_ ..........
U --- -------------------------- ............. ................. .......
............e---------------- .......................... . .... ............................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposdl System in accordance witl
the provisions of'MITIE 5 of the State Sanitary Code— The undersigned further agre"8s not to place the system in
operation until a Certificate of Compliance has been issued by,the board D health.
11C board
11'��........ .. .... ..*.. .......
Signed
ed- ..... ............................... Z.........Date................
ApplicationApproved By..........................................I........................................................ ........................................
Date
Application Disapproved for the following reasons:...........................................................................Z
............m................._
........................................................................................................................................................................................................
Date
3>
PermitNo......................................................... IssuedL1_—!;L.........................................
Date.,
No._ :3".:C� ... ........................_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................... ..................O F...............---.....................------------------------------.....................
Appliratiou for Dhiposal WorkS Tomitrnrtinn amit
.Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at A
•. .....:`:I,. f°............................................................. --•--•--••--•-•------------•-•-•----------- ............................. ...------.
g l�LJtion- s or Lot No.
IC° " c.....-•-•-•---------••---------•-•--... -------- ------ ------- .............................................................
O e o e ddress' r e e t
a Installer Address
Type of Building Size Lot..�Z. �..Op__.._..Sq. feet
U Dwelling4_0 No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures ................................. .
W Design Flow............................................gallons per person per day. Total daily flow............................_...............gallons.
1:4 Septic x Tank—Liquid capacity_-----_ gallons Length idth-- ----' Depth................
Disposal TenchNo - - Wdth Total Length ------- -Tootal leaching area - sq. ft.
W I
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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x -: fi
Description of Soil-----------
x
U =
W -•--•-•----------•--------- -------•----------......... •-•-•--•----------•-•---•--•-•---•--... ... ---- . --------•---•-
UNature of Repairs Iterations—Answer when applicable _ �- .f ".dt` e ................
_. ------- ------ ------ ---- ---------------------------•---••-------------
Agreement:,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board f health. Sr k
Signed ...f� ..-'�- .. .. -
- Date
ApplicationApproved By.................................................................................................. ........................................
Date r
Application Disapproved for the following reasons:............................................ _•"_ _
- -
-----------------------------------------------------------•---••------------••-•-•---•••--_-
Date s
� aep
PermitNo......................................................... Issued .k_' ...........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL H
..........................................
(9rrtifiratr of ToutpliFatta
IS TO'CEOY, That the Individual Sewage Disposal System constructed ( ) or Repairedbyal�e..._...A. . ------•----_...
Z
nstaller
----------------
has been installed in accordance with the provisions of TI E r f The State Sanitary Co as"I'l scribed in the
application for Disposal Works Construction Permit No.kI.—.. ----------------- dated-// -- ------------_........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST U AS A GUARANTEE THAT THE
SYSTEM W. L NCTION SATISFACTORY.
DATE..4.A �--•---•--•--•........................................................ Inspector.. .... ----- •-•- ••-•`-•••---•-•---•-•-••-•-•-......_•--•••-•------------....•-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l ,. t>y ........................................... FEEOF.................---......----------------•------------•--••......................... /�
// ---.... .......................
t a; orh nstrnrtion rrnt�t
Permission is he eby granted , -••••--•-••---••..............................•----•-•.........---•-•••-••--•••-•---•-
to Constr ( or epaif ) an dividual e os tern----
At.�� ---- ..
Street
as shown on the application for Disposal Works Construction Permit No_ _______________ ate _..a. ..............
_t
rt. . Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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D 1 N A R D O ADD 1 T 1 O N S FAX (508)428-4295
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1 0 ARCHITECTURAL INNOVATIONS
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