HomeMy WebLinkAbout0746 MAIN STREET (COTUIT) - Health (2) 036 - 035 Ij
No. Z —7 J Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippliLAtion for Disposal 6pstem Cunstrurtion Permit
Application for a Permit to Construct( ) Repair()o Upgrade( ) Abandon( ) ❑Complete System J]Individual Components
Location Address or Lot No. 74(p 14,4/11 S-T d4t)Tu IT Owner's Name,Address,and Tel.No.
IL'lsl0.G6.4P_t;;;-r Kb QN(3(_0Aj
Assessor's Map/Parcel tj. ( d 7 60T u
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
NA
Type of Bu ding:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building PIGS jD&M 04-- 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 when applicable) X0 57*a- AP ice) N_a 0 D— R OK
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 Certificate of
Compliance has been issued by this Board of Health
Si ed Date l
Application Approved by ` Date
Application Disapproved by Date
for the following reasons
Permit No.09?/1p "� (� Date Issued ;j L)
+ No. (.F .- T . Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN'OF BARNSTABLE, MASSACHUSETTS
ftplication for,*fsposal"6pstem Construction Permit
Application for a Permit to Construct( ) Repair(k) Upgrade( ) Abandon( ) ❑Complete System ]Individual Components
Location Address or Lot No. '7% �L1.4IN 5oTco t'dP Owner's Name,Address,and Tel.No.
'MAa<ko4$r<T 1<oa.Nc3c-wM
Assessor's Map/Parcel 03 6 03 O do-T V tT
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
N/j4
Type of Budding:
ding: k ......
Dwelling No.of Bedrooms Lot Size 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 when applicable) -T Q 5To,L L A)&tg) bi-a y DB OX
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 Certificate of
Compliance has been issued by this Board of Health.
r C
' Si ed Date
Application Approved by Date
Application Disapproved by Date
i for the following reasons
Permit No. r:- Lam/�O �� 4, Date Issued 5 L)
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal systems Constructed( ) Repaired Q( ) Upgraded( )
Abandoned( )by CAP6xcj(w E E&)7-R&4ISte'
at 7 of, M4-10 S T OT V CT has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NaPO/� dated
Installer 1 Designer IJ
#bedrooms n I Approved design floc gpd
The issuance o this p it shall not be construed as a guarantee that the system w'C`l� ct n as desig ed.
Date S 1 Inspector
11
No. / 61 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair OO Upgrade( ) Abandon( )
System located at -7 L/& 14A I AJ S-T G"0-ru 1-r
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 b Completed within three years of the date of this permit.
Date �� r'C9 Approved by
AsBuilt t Page 1 of 1
TOWN OF BARNSTABLE
LOCATION 7y6 j �r�n �T . SEWAGE # 1QL 36 y
VILLAGE_ � u�r ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO: 3./� Gi�o»+6P/'^�'Sdy1h(r
SEPTIC TANK CAPACITY
LEACHING FACILITY-(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
\131 y/
` \` () /I
0
i
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=036035&seq=1 5/12/2016
ay 15 2016 16:52 Jim The Inspector Man 5085349919 page 1
�• 03(v -035 3
�f Commonwealth of Massachusetts
. Title 5 Official Inspection Form
P Subsurface Sewage Disposal System Form- Not for Voluntary Assessments -.
746 Main Street
Property Address
Margaret Kornblum -
Owner Owner's Name
information is r co
required for every Cotuit MA 02635 5-13-16,
page. City/Town state Zip code.. Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any,
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms \` N OF hN II �'��i,�
on the computer, �. ,, �����
use only the tab 1. Inspector:
key to move your DAMES
cursor-do not James D.Sears
e the return Name of Inspector
key. CapewideEnterprises, LLC
Company Name �i F � 0
153 Commercial Street
Company Address
Mashpee MA 02649 - t
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number license Number
B. Certification t
I certify that I have personally inspected the sewage disposal system at this,address and that the
information reported below is true; accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems, I am a DEP approved system inspector pursuant to Section 15,340 of
Title 6 (310 CMR 16.000).The system:' i
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority d
5-13_-16
;nspectofs Signature - Date
The system inspector shall-submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,00D gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system'will perform in the future under
the same or different conditions of use.
15ins•3113 - Title 5 Offwlal Inspection Forms Subsurface Sewage❑ISPOsal System•Page 1 of 17
r
May 15 2016 16:52 Jim The Inspector Man 5085349919 page 2
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
746 Main Street
Property Address
Mar aret Kornblum
kit
Owner owner's Name
information.is COW MA 02635 5-13-16
required for every State Zip Code Date of Inspection
page. City/Town
B. Certification (cont.)
Inspection Summary: Check A,B,C;D or /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 system is a 1000 Gal. Tank D Box and it.
Y p
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
a
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N' ND)for the following statements. If"not
f
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):
15ins•3113 Title 5 Official Inspection Form:subsurface Sewage Dispose System•Page 2 of 17 #
May 15 2016 16:52 Jim The` Inspector Man 5085349919 . page- 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
information is Cotuit MA 02635 5-.13-16
required for every
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cant.):.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
' to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ .Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑, obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health, .
safety and the environment:
Cesspool or privy is within 50 feet of a surface water +
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 17
r
May 15 2016 16:52 Jim The Inspector Man 5085349919 page, .4
Commonwealth of Massachusetts s
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
746 Main Street r
Property Address z
Margaret Kornblum
Owner Owner's Name
information is Cotuit MA 02635 6-13-16
required for every
page. Cityrrown State Zip Code Date of Inspection
1
B. Certification (cunt.)
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:
El The system has a.septic tank and soil absorption system(SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet.of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems: ;
You must indicate"Yes" or"No to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due'to overloaded or
0 ® clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert.due to an overloaded
® or clogged SAS or cesspool
Liquid depth in 1111111111111111W is less than 6 below invert or available volume is less
❑ ® than '/2 day flow P/71
(Sins•3!13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of t7
May 15 2016 16:52 Jim The Inspector Man 5085349919 page 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
information is required for every COtUIt MA 02635 5-13-16
page. Cityr town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® -Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
i
❑_ ® Any portion of a cesspool or privy is within a Zone.1 of a public well.
An portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® YP P P � Y P � PPY
❑ ® 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 passesif 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
0 ❑ the system is within 400 feet'of.a surface drinking water supply
El 0 the system is within 200 feet of a tributary to a surface drinking water supply �<
❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well ;
If you have answered"yes"to any question in Section E the system is considered,a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
l5ins-3113 Title 5 official Inspection Form:Subs dace Sewage Disposal System-Page 5 or 17
• i
May 15 2016 16:52 Jim The Inspector Man 5085349919 page 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
746 Main Street
Property Address
Margaret Kornblum
Owner Owners Name
information is Cotuit MA 02635 5-13-16
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
Z ❑ `Has the system received normal flows in the previous two week period?
El
IDHave 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?
m
® ❑ 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 Z. Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of.the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D., System Information
Residential Flow Conditions:
Number of bedrooms (design): NA Number of bedrooms (actual); 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of W .
May 15 2016 16:52 Jim The Inspector Man 5085349919 page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
746 Main Street j
Property Address
Margaret Kornblum
Owner Owner's Name
information is
required for every Cotuit MA 02635 5-13-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description: ,
The system is a 1000 Gal:Tank D Box and pit. !
Number of current residents:
Does residence have a garbage grinder? ? El Yes ® No
1s 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
2014-136,000Gal
Water meter readings, if available(last 2 years usage(gpd)): 2015-136,000GaI's
p
Detail
Sump pump? ❑ Yes ® No
Present
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc,):
Grease trap present? ❑ Yes ❑ No
r
Industrial waste holding tank present? ❑ Yes 'D No
j
Non-sanitary waste discharged to the Title 5 system? . ❑ Yes ❑ No
a
Water meter readings, if available:
t5ins-3113 Title 5 Ofncial Inspection Form:Subsurface Sewage Disposal System Page 7 0117
May 15 2016 16:52 Jim The Inspector Man 5085349919 page 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
Information is required for every Cotuit MA 02635 5-13-16
page. City/Town State. Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA 3
7
Was system pumped as part of the inspection? ❑ Yes ® No '
If yes,volume pumped: gallons
f
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
A
❑ Privy
• r
❑ Shared system (yes or no) (if yesi attach previous inspection records; if any)
't
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(descrlbe):
a
15in5.3113 Title 5 Official Insoection Form:Subsurface Sewage Disposal System-Page 8 of 17
• - i
May 15 2016 16:53 Jim The Inspector Man 5085349919 page 9
q
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
746 Main Street
Property Address
Margaret Kornblunn
Owner Owner's Name
information is required for every Cotuit MA 02635 5-13-16
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1990 Permit#90- 364 1 D Box is New 5-2016.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
3,
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.):
Pipeing is 4" PVC SCH 40. _x
Septic Tank (locate on.site plan): q.
2'
Depth below grade: feet
Material of construction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
z
3
•d
- If tank is metal, list age:
years A
v
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions' 1000 Gal. Precast H-10
4'
Sludge depth:
R
t5ins•3i13 Title 5 Official Inspection Form:Subsurfeoe Sewage Disposal System-Page 9 or 17
May 15 2016 16:53 Jim The Inspector Man 5085349919 page 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
information is required for every COtUIt MA 02635 5-13-16
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont,)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
26'
Scum thickness 2"
81
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 1611
i
How were dimensions determined? A Sludge u g Tape ;
Sle Judge ,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, y
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at T below grade. (Two inlet tee's, outlet tee.. No sign of leakage
or over loading
Grease Trap (locate on site plan): -
Depth below grade: feet
Material of construction: ,
❑ concrete []metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
t
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
15ins 3.!13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
May 15 2016 16:53 Jim The Inspector Man 5085349919. page 11
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
information is required for every Cotuit MA 02635 5-13-16
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on,site plan):
f
Depth below grade: "}
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
- i
Capacity: gallons
Design Flow: gallons per day
Alarm present: [] Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No Y
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3f13 Tills 5 Official Inspedion Form:Subsurface Sewage Disposal System-Page 11 of 17
• 3
k�
3
May 15 2016 16:53 Jim .The Inspector Man 5085349919 page 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
Information is COtult MA 02635 5-13-16
required for every
page. City/Town Slate Zip Code Date of Inspection
D. System Information (cont.) -
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above.outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"xlV-33" below grade w/cover at 6" Box is new 5-2016 Wone line out.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ Now
Alarms in working order: ❑ Yes, ❑ No" t
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required): . 4
If SAS not located, explain why:
a
,i
r
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
May 15 2016 16:53 Jim The Inspector Man 5085349919 page 13
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
Information is Cotuit. MA 02635 5-13-16
required for every
page. Citylrown State Zip Code Date of Inspedion
D. System Information (coat.) }
Type:
1
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ . Teaching 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 s
vegetation, etc.):
Leaching is a 1000 Gal. H-20 precast pit. Pit at 23" below grade w/cover at 2". 2' water in
pit w/no sign of over loading or solid carry over. No high stain line
r
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
15ins•3113 Title 5 Official Inspection Form:Subsueace Sewage Ditiposal System-Page 13 of 17
May 15 2016 16:53 Jim The Inspector Man 5085349919 page 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
x 746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
Wormation is Cotuit MA 02635 5-13-16
required for every
page. CityfTown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
s
Privy (locate on site plan): y
Materials of construction:
f
Dimensions
Depth of solids
Comments.(note condition of soil,signs of hydraulic failure, level of.ponding, condition of vegetation,
etc.):
i�
r
,a 3
zi
.. 4
15ins 3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
1.
ti
May 15 2016 16:53 Jim The Inspector Man 5085349919 page 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
information is required for every Cotuit MA 02635 5-13-16 .
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cons.)
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 F
4
57
d 2.
0
4
i
15ins-3113 Title 5 affiolei hspecson Form:subsurface Sewage Disposal System•Page 15 of 17
- y
May 15 2016 16:54 Jim The Inspector Man 5085349919 -.page 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w
°y 746 Main Street
Property Address
Margaret Kornblum
Owner owner's Name
information is Cotuit MA. 02635 5-13-16
required for every page. City/Town State Zip Code date of Inspection
D. System Information (cont.)
S
Site Exam:
❑ Check Slope _ M
❑ Surface water
❑ Check cellar
❑ Shallow wells N0 }
20'+
Estimated depth to igh 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: pate
® Observed site (abutting pro pertylobservatioh hole within 150 feet of SAS)
❑ Checked withr 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:
Abutting property and rear of lot drop's off
d
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
- t51ns 3113
Title 5 Official Inspection Form:Subsirface sewage Disposal Svstem•Pape 16 of 17
May 15 2016 16:54 Jim The Inspector Man 5085349919 page' 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
746 Main Street
Property Address
Margaret Kornblum
Owner Owner's Name
information is required for every Cotuit MA 02635 5-13-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection.Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater .
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
x
t5ins•3113 Title S Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE
VV'
,a
LOCATION_ � r yhsT _ SEWAGE # 11�v.:36
VILLAGE l_ fij� ASSESSOR'S MAP & LOT
INSTALLER'S NAME,& PHONE NO.J. �»,6�/' ?'SdV► hf�h
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)_ /Ji r (size) 1 L
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER ,,"®��
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �,
i
r
o_
f
iw
R� �G
�p 2 ...30--00
Fizz..
No----rl.�..:.�,t .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applira#ion for Disposal Works Tour rnr#ion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at:
746 Mai-n Street Cotuit
Location-Address or Lot No. Ar'
R d e r--....
----•-•-------------.... • -..-6
W
J.P.Ma e o mb e r J r. Owner Address-........ -
Ga
Installer Address
d Type of Builtg 3 Size Lot----------------------------Sq. feet
U Dwelling No. of Bedrooms............................................Ex Expansion Attic a g— p ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ---------------------------------•------------
W Design Flow......................._-----------------:gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No--------------------- Diameter..-.--------.------- Depth below'inlet............__._._.. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.-----------------------------------....
W
1_4 Test Pit No. I................minutes per inch Depth of Test Pit---.--.............. Depth to ground water-------------.----_---
44 Test Pit No. 2................minutes per inch Depth of Test Pit------.-..----.._--- Depth to ground water.-----.-.-_.---.--..---.
a -------------------------------------------------------------j--•--••---•---•--......--•----•--••---.........................................................
0 Description of Soil...............................................................................---------------------------------------•----••--------------------------.......---.-----
c4 ......................................Sand........................................................................................................................................................
W
VNature of Repairs or Alterations-Answer when applicable.........................:.............................----------------------------------------
1-1000 tank 1-1000 leaching pit.
.------••-•------------------------•--•----------•--------------------------------................-----......------------------------------------=---------------------------.............._......----
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 by the
board of health.
Signed .. . ....ems %7ZZ4r ------- /!.319P..
Date
Application Approved By ................- - <E�t .e`.�.� --------------.....----------------- --- ll� 1 0
Date
Application Disapproved for the following reasons- .................................................------------------------------------------------------------------------------------
Dale
Permit No. .......?. Issued
Date
No.... Fim.. ...30_.20
THE COMMONWEALTH OF MASSACHUSETTS
.' BOARD OF HEALTH
TOWN OF BARNSTABLE
Allp iratilan for Uispuiitti Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at: �-
•746 Main Street Cotuit -•--------------------------------------------------------------------------•---........---•---•--
•-••••• Location-Address or Lot.-No.
Rvder
.._. ...._.... - -. . ............. ....•---------------------- - --= -•----•-••-----------------------•--•-------...--•---...........-----•...--•-..............••---
W J....Macomber Jr. Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
DwellingL No. of Bedrooms.......... ................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
44 Other fixtures ------------_---------------- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity..._.......gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___--___-_-_--_---_--_.
f� Test Pit No. 2.........:.....minutes per inch Depth of Test Pit.................... Depth to ground water................_.......
a ---•--. - -------------------------------------•......................................................................................
Descriptionof Soil-------------•----------•-------------------------------•------------------....:........................................................................................
U •-------------------------•--•------ and.......------------------. ......-•-••-•-•-•-•.............-•-•-----•....• ._..._
W .
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-1000 tank 1-1000 leaching fait.
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 by the board of health.
Signed --r. /� -?? OFF ` ''�---------- -------R/I q/an
Dare... ..........
Application Approved By ...............
------------ ------------------------------------------------------------- �= ,I.ea. 90
Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------.....-------------- ....----------- -----.....------------
PermitNo. ........�� .....3.�� L/ Issued............ ............................ .............................-.-.......-....-.....................
l Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
V�ertifirate of Ou'amplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ,) or Repaired kXX )
by J,PMacomber Jr.
Insmller
at -746 Main Street Cotuit
----------------------------------------------•------....----------------------------- --•---------------------------...------------ ........................................................---------
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. ....�'9'o - .��.. -t....... dated .......77............................_..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. /
DATE ........................ ....... Inspector .......`..` l/ ------------------
llc
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
M11110.0ttl Works Tonotrmfivit f amit
Permission is hereby granted........Jt ',MaCOmber
...Jr............................................................................................
to Construct ( ) or Re air `t �)➢ an Individual Sewage Disposal System
atNo.- 7j..Main Scr..... ........................................................•----•.........
Street p.
as shown on the application for Disposal Works Construction Permit No.,W:24_�.. Dated..........................................
-•---------------.............---------------------------
DATE..............�..`_.1.�- --�)-.._..----....--•-
-- ....... �rd of Health
FORM 36508 HOBBS B WARREN.INC.,PUBLISHERS
AsBuilt Page 1 of 2
TOWN OF BARNSTABLE
LOCATION 7y�, rrin .�'T SEWAGE � - fo
VILLAGE_ ASSESSOR'S MAP S. LOT
INSTALLER'S NAME & PHONE NO-3./� G�orH6p/'4--5,m h(r
SEPTIC TANK CAPACITY� L
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
+31 Y
0 � lil
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=036035&seq=1 4/25/20.16