HomeMy WebLinkAbout0545 MAIN STREET (COTUIT) - Health i k t�Ma
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c
<cGM 545 Main St.
Property Address
Earlene MacDowell ct, 0C)
Owner Owner's Name
information is required for Cotuit Ma. 02635 11119/2007
every 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.
Important:filling
When g out A. General Information.
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC
Company Name
rab P,O.Box 763
Company-Address
Centerville Ma. 02632
Cify/Town State Zip Code
(508)428-4028 S 14454
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate'and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system: >r,
® ..Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
11/19/2007
Ins ctor's i ature Date _
� -rt
The system inspector shall submit a copy of this inspection report to the App ving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000'gpd or greater, the inspector and the system owner shall-submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent•to the buyer, if applicable, and the approving authority.
****This report only describes,conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
I the same or different conditions of use.
t5insp-08/06 / Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form - Not for Voluntary Assessments
M 545 Main St.
Property Address
Earlene MacDowell _
Owner Owner's Name
information is required for Cotuit Ma. 02635 11/19/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (coat.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: '
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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.
❑ 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)eaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ 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):
h ❑ broken pipe(s)are replaced
❑ obstruction is removed
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 545 Main St.
Property Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit Ma: 02635 11/19/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
r
❑ 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
❑ obstruction is removed
ND Explain:
1 .
C)' Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
1
❑ 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.
M ❑ 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.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
l
Commonwealth of Massachusetts /
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 545 Main St.
Property:Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit Ma. 02635 11/19/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.-
Method used to determine distance.
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be.
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1Y2 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.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
545 Main St.
Property Address
Earlene MacDowell
Owner Owner's Name _
information is Cotuit Ma. 02635 111/19/2007
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100rfeet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of.custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system'is within 200 feet of a tributary to a surface drinking water supply
❑ El 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.
t5insp•08/06 Title 5.Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of'Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
545 Main St.
Property Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit Ma. 02635 11/19/2007
every page. City/Town. State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
®' ❑ Pumping 'information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period? .
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 N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components., excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® ❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ E Existing information. For example, a plan at the Board of Health.
❑ ®l 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)]
I .
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
545 Main St.
Property Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit Ma. 02635 11/19/2007
every page. City/Town State Zip Code. Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 1
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required]. ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? - ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2006:25,000
g ( y g (gpd)): 2007:40,000
'Sump pump? ❑ Yes ® No
Last date of occupancy: 11/19/2007
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste,discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date
I Other(describe):
t5insp•08/06 l Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 545 Main'St.
Property Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit Ma.: 02635 11/19/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Capewide Enterprises,LLC
Was system pumped as part of the inspection? ® Yes ❑ No
If yes,.volume pumped: 1000
gallons ,
How was quantity pumped determined? Measured
Reason for.pumping:
Maintenance �
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)
❑- Tight tank. Attach a copy of the DEP approval
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
System,installed 1983
i
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 545 Main St.
Property Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit Ma. 02635 11/19/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
• 1
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: 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: 8'6"x4'10"x57"
Sludge depth: 0
Distance from top of sludge to bottom of outlet tee or baffle na
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle na
Distance from bottom of scum to bottom of outlet tee or baffle na
How were dimensions determined? tank is empty
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
F
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments
° 545 Main St.
M
Property Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit Ma. 02635 11/19/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septis tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
t
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: bate
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
t5insp-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachu-setts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
545 Main St.
41M 50ye .
Property Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit Ma. 02635 11/19/2007
'
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day ,
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches,- etc.): .
*Attach copy of current pumping contract.(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
i
e
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
f
545 Main St.
M
Property Address
Earlene MacDowell
Owner Owner's Name -
information is required for Cotuit Ma. `02635 11/19/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS.not located, explain why:
Type:
® leaching pits number: 1-1000 gallon
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No evidence of hydraulic failure.Water to invert in leaching pit was 39" at time of
inspection.Stain line was 24"to invert.
t5insp•08/0.6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 545 Main St.
M
Property Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit Ma. 02635 11/19/2007,
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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.):
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Map Page 1 of 2
Town of Barnstable Geographic Information System
Parcel Viewer Custom Map Abutters Map Size 0 Zoom Out In
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4%.
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20 Feet
Set Scale 1" = 20 I Aerial Photos
r—,,inht,)onR-,)nn 7 Tr... of P— M.hlo INAA All rinhfc ro on.
http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=021006&ma... 11/19/2007
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 545 Main St. '
Property Address
Earlene.MacDowell
Owner Owner's Name
information is required for Cotuit Ma. 02635 11/19/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) _
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.
1
i
t5insp-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 545 Main St.
Property Address
Earlene MacDowell
Owner Owner's Name
information is required for Cotuit 'Ma. 02635 11/19/2007
every page. City/Town State Zip Code Date of Inspection
:D. System Information (cont.)
.Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: Botton of LP 40'
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:
AS-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
.You must describe how you established the high ground water elevation:
USED:Gaherty& Miller model 12/16/94 ground water elevations. USED:Technical Bulletin 92-000-01
plate#2 annual ranges of ground water elevations.
I
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Town of Barnstable
Regulatory Services Department
� �►� Public Health Divislon-
��"°'Fv 3i$ 200 Main Street, Hyannis MA 02601
FAX: 508-790-6304 Office: 508-862.4644 ,
Thomas A.McKean,CHo
December 18, 2006 ,
Earlene MacDowell
P.O. Box 156 Y
Cotuit, MA 02635
l � r
Dear Property Owner, ' w
Please be aware that the 2007 fees for registering g g your rental units are du71
I anuary-o
1, 2007. The fee is $90 per unit [$25 for each additional unit on the same property . ;
Please send payment to: Nco
Town of Barnstable "' '
200 Mairr Street,
Hyannis, MA 02601
to the attention of the health department: IQA
Thank you for your cooperation. ^�� �
Sincerely,
Caine Barrett
Division Assistant U 'iW ` ' rf
a� (40J
6Pr
DATE: 6/29/9
PROPERTY ADDRESS:--545. Main Street 9 i
--- -------------------
Cotuit
------------------------
-----------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 -1000- ga-11on septic tank. . 1 -1000 gallon leaching pit packed in stone... I
i
1 -distribution box. All Sch. 40 4" PVC pipe,
Based on my Inspection, I certify the following conditions:
I
This -is a title five septic system
The septic system is in proper working order
at the present time.
I
i
I
SIGNATURE:_
Name: _j I?_Ka_cOmhPr_,I�.:
i
Company:_J_P_Macomber_&—Son Inc .
A d d r e s s:__BQx 56_______------
Centerville,Mass . 02632
Phone:- 508_775-3338
i
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
J.
JOSEPH P. !MAonMnER & SON, INC.
Tan ks-Cesspools-Leachflolds
Pumped & Installed
Town Sower Connoctlons
P.O. Box 66 Centerville, MA 02632-0066
7 5-3338 75-6412
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
Address of property 545 Main Street Cotuit,Mass .
Owner' s name Estate Of Bernice L. Hoxie
Date of Inspection 6/28/95
PART A
CHECKLIST
Check if the following have been done:
Yes Pumping information was requested of the owner, occupant, and Board of
Health.
components have been pumped for at least two weeks
No None None of the system p p p
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
Yes As built plans have been obtained and examined. Note if they are not
available with N/A.
Yes. The facility or dwelling was inspected for signs of sewage back-up.
Yes The site was inspected for signs of breakout.
Yes All system components, excluding the SAS, have been located on the
site.
Yes The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
Yes The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
Yes The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance ,.of SSDS.'
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
2 number of bedrooms
_4— number of current residents
NO garbage grinder, yes or no
YES laundry connected to system, yes or no
—No seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: 1`�r
UNx Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
No pumping record New system installed 11 /12/93 L
Now Deceased.
NO System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
YES Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Nn Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: 17 months Source of informatiom. J.P.Macomber & Son Inc
Installer. Plan on file at Board Of Health Town Of Barnstable
NO Sewage odors detected when arriving at the site, yes or no
1
9
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: Yes 1000 Gallons
(locate on site plan)
depth below grade: 12"
material of construction: XXX concrete metal FRP other(explain)
dimensions: L-8 ' 6" W=4 ' 10" H-5 ' 7
None sludge depth
distance from top of sludge to bottom of outlet tee or baffle
None scum thickness
None distance from top of scum to top of outlet tee or baffle
None distance from bottom of scum to bottom of outlet tee or baffle
��IIIIIIpII�E i
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
Rec: Pumping once every 3 years Structurally sound Nn PyitjPnr-P
of leakage No repairs nPPdPd _
DISTRIBUTION BOX: _
(locate on site plan)
None depth of liquid level above outlet invert
Comments:
,(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into, or out of box, recommendation for repairs, etc. )
Box is level No solids cagy over. No evidpnrp mhP
owner deceased. Did not have hardly any i�agP_
PUMP CHAMBER: No
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, .
recommendations for maintenance or repairs,etc. )
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : Yes
(locate on site plan , if possible ; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number 1 -1000 galloa( it
leaching chambers and number
Packed in stone-
leaching galleries and number
leaching trenches, number, length
leaching fields , number, dimensions
overflow cesspool , number
Comments :
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
Soil fine sand. No Hydraulic failure. no ponding. vegetation norm
No repairs needed. Tank should be pumped once every 3 years.
CESSPOOLS (locate on site plan) :
number and configuration NONE
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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY :
(locate on site plan)
materials of construction NONE
dimensions
depth of solids
I
Comments :
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation,. recommendations for maintenance or repairs, etc. ) .
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L'_SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
l
Qf lee;
� , door •_. ,,,,,,
DEPTH TO GROUNDWATER
depth to groundwater
met-hod of dgtermination appXDximation: _
7
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances . If "not determined" , explain why not)
-o Backup of sewage into facility?
NO Discharge or ponding of effluent to the surface. of the ground or
surface waters?
NO Static liquid level in the distribution box above outlet invert?
No Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
mn Required pumping 4 times or more in the last year?
number of times pumped
Nn Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent? )
Is any portion of the SAS, cesspool or privy:
NO below the high groundwater elevation?
_ O within 50 feet of a surface water?
NO within 100 feet of a surface water supply or tributary to a surface
water supply?
No within a Zone I of a public well?
Nn within 50 feet of a bordering vegetated wetland or salt marsh-
(cesspools and .privies only, not the SAS) ?
mo within 50 feet of a 'private water supply well?
No less than 100 feet but greater than 50 feet from a private water
M supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water anal,
. for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
TOWN OF Barnstable' BOARD OF HEALTH-==------------'-----
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 545 Main Street r ntiiit,Mass
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Fstat-P of Bernice L- Hoxie
PART D - CERTIFICATION
NAME OF INSPECTOR J.P.Macomber Jr-
COMPANY NAME J.P.Macomber & Son Inc
COMPANY ADDRESS Box 66 Centerville Mass- 02632
Street Town or City State ZIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (790 ) 15 - 78
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa-1 system a
this address and that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
XXXX System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails to,
protect the public 'health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature ` Date 6Taq�gS
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
4 * If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doc
! -IQCcmmonweartn of fvl=ccn,useTTS
Executive Office of EnvironmenTcl Affcrs
i Department of
Environmental Protection
' Water Pollution Control Technical Assistance and Training Sections
wuuam F.we+d
Gownar
Trudy cox.
s.aw•y.EOEA
Thomas B.Powws
A,avq w
06/12/95
ATTN: Joseph P. Macomber, Jr.
Joseph Macomber and Son
PO Box 66
Centerville, MA 02632-
....... ......
Dear Joseph P. Macomber, Jr. ,
I am pleased to inform you that', you have attended training, met
the experience qualifications, and have passed the Title 5 System
Inspector exam, pursuant to 310 CMR 15.340. The passing grade for
the exam was 39/52 or 75%. Your grade was 81%.
This is an official notification that you are a Certified Department
of Environmental Protection System Inspector pursuant to 310 CMR 15.340 .
You will receive a System Inspector certificate at a later date.
If you have any futher questions, please write to me at the following
address:
Kimball Simpson
D.E.P. Training Center
50 Route 20
Millbury, MA 01527
Thank you very much for your time and consideration in this matter.
Sincerely,
Kimball T. Simpson,
NDEP Training Center Director
(2405) Route20 9 Millbury, MA 01SZ7 • FAX 508-755-9253 • Telephone 508-756-7281
I
Water
Conservation
SAVE Tips
ME!
CHECK FOR LEAKS :
Water Loss in Gallons Due to Leaks
Leak
this Loss Per Day Loss Per Month
Size
• 120 3,600
• 300 10,800
• 693 20,790
1,200 36,000
• 1,920 57,600
0 3,096- 92,880
0 41296 .128,980
® . 6,640 199,200.
6,9,84 200,520
8,424 252,720
® .9,888 296,640
AVh
. 11,324 339,720
ANIL
12,720 381,600
14,952 448,560
., TOWN OF BARNSTABLE
LOCATION A, fd//tl !gr SEWAGE #
VILLAGE co 7r tl / ASSESSOR'S MAP & LOT ilf;lt.4 d Cs
INSTALLER'S NAME & PHONE NO. 04�- MqC 6-A4 eet -
SEPTIC TANK CAPACITY / 0
LEACHING FACILITY:(type) Oe/r (size) /, G Peg
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
R
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �,/
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No.- 1.7:..J6 Fps..........30.00..
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
r able Conservation Depar men BOARD OF HEALTH
5'' TOWN OF BARNSTABLE
08igned Appliration for Diripooal Wor1w Tomitrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
545 Main Street Cotuit
.........................................•--•-----•--.......---------------•----•--•------..------ ---------•------------••••-------•-••---•------•-••-•---•--.........----••---•-------•----•-----•-
Location-Address - or Lot No.
I.P.............................. ..............................`
owner Address
W J .P .Macomber Jr .
d Inscauer r Type of Building Size Lot...........................Sq. feet
U Dwelling-X No. of Bedrooms...............2........-------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------- -__-____-_-.___. Showers ( ) — Cafeteria ( )
aOther fixtures ---------------------------------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity-1Q0.Q.gallons Length--.............. Width................ Diameter---............. Depth................
Disposal Trench—No. .................... Width-................... .total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----I............... Diameter---6............... Depth below inlet....6.............. Total leaching area..................sq. ft.
Z Other Distribution box (XX) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x -------------------------------------------------------------------•----------------........................................................................
0 Description of Soil..................isrl.d.............................................................................................................................................
W
---------------------------------•----------.......----------------------------------••......------ .................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.----.Omitted c e s s p o 01-s .___1-?0 0 0 gallon
tank 1-distribution box 1-1000 gallon leach pit packed in stone .
...-----•----------------------------------•----•---•------•------•----------------.................----•-------•-•------•---•------•----•---...-------------••--•-•----•-••--•--•--•---•---•--•---.....
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 Compliant has b en i sued y the b ar f health. .
Signed .... ..: .. . .,.........................11 .8....9.3..............:..----
Dace
Application Approved By ..........I �1.... ' ._ . ---------------------- r.....
Application Disapproved for the following reasonr: . ....................... .... ....................................................... ..................................
................................................... ....... ..................................................................................................................... ..... ............ ......................................:.
q' Date
Permit No. ....1...� ..^ ...i..:0........................... Issued ..................................
Date
NO.... .- r� - / Fas... .............�.....
T_HE COMMONWEALTH OF MASSACHUSETTS V/
- BOARD OF HEALTH
ADTOWN OF BARNSTABLE
�1 Appliration for Diripwml Work,g Tomitrurtion Prrnttt
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
545 Mal ................................... ------ .--...
Location-Address or Lot No.
Reruii cLe_.Eoxie--•--------------------------- ...._.-........................
W J .PMa. combe.r O�cner Address
...Jr: - Address
Instal Ier Address
d Type of Building Size Lot............................Sq. feet
Dwelling Y No. of Bedrooms.............. :__.-.__--_-_-_-__---_.-_.-_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.........1................ Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------•----------------•------------- ---------•---•---•-••-••--•-•-•••••......--•-•---•••--•--•-•.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity110.0_f?_gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench— No. .................... Width-------------------- Total Length.-.................. Total leaching area....................sq. ft.
Seepage Pit No...J-............... Diameter...6............... Depth below inlet....6.............. Total leaching area..................sq. ft.
Z Other Distribution box (XX) Dosing tank ( )
aPercolation Test Results Performed by............ -•---•-----••-- -•••---•-••--------•--•-•------•••--•-----••• Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•--•-•--•.....................••---------••-•......-------•-------•--------.._......----•-•---•....................•------•--•---•- ..........
-------
.....
O Description of Soil---------------.Sa n-`l................................................................................................................................
x
c,
w J
UNature of Repairs or Alterations—Answer when applicable._....Omi-t-ted- cesspools. 1-1000_.•gallori
tank 1-distribution box 1-1000 gallon leach pit packed in stone.
............. •-----------------------------------•--------•-------------•----------......-•-•---------------•----------.......------.....-------------•--------------------------------...--•-------•-.
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
,,b//een,issued y the b,ar of health.
Signed .........fir '1....�1... ///� I.. .A......................... ......................
Date
Application Approved By ............ -
-.L ,a. ........ ... .f....-... tea ...
Date
Application Disapproved for the following reasons: ....................................... .......... ......... ..-.................--- .........--..................
................................................................. ........ .................------- ---------...---.. ............................:..................--------------- -------------. ........................................
Permit No. ... .. ..-.. .... Dale
1...n . .......... Issued .... .. ..........................
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
�El"tifira E of Q-1jar Cptiancie
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX)
J.P.Macomber Jr.
by.................................. ... ..............................................
': Installer
545 Main Street Cotuit
at ...................................... ... ................... ........ ................. ....................................................--------------------.........................................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. 0. dated ......................._.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............_...........�..�._._ .. .".�.......... ... - - .... - .. Inspector ......... .. - --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
FEE......$....3.0...0 0
Rapooal Workii Tonatrurtion rrutit
J.P Macomber Jr.
Permissionis hereby granted....................................................................................................--•-•-.........-•--•---•--........--•••---
to Construct ( ) or Repair, (XX) an Individual Sewage Disposal System
545 Main Street Cotuit
Street 9� //O
as shown on the application for Disposal Works Construction Permit No--------------........ Dated...........................................
...............................\- .....0........................................................
-_••----------------------------•--- Board of Health
DATE.......��------ ----�--�--- -
FORM 36508 HOBBS R WARREN.INC..PUBLISHERS
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