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Commonwealth of Massachusetts
Title 5 official Inspection Form =
Subsurface Sewage Disposal System Form •Not for Voluntary Assessmentss
2
978 Main Street
Property Address
Joseph Cerretani -rr
Owner Owner's Name
information is Cotuit F/ MA 02635 11-5-18 �`_'
required for every i
page. CityfTown 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.
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Important:When A. Inspector Information c514 /3y�3
filling out forms
on the computer, ; JAMES :R,
use only the lab James D Sears = _
key to move your Name of Inspector
cursor-do not Capewide Enterprises
use the return Company Name
key. Company
153 Commercial Street
1�=11 Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
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
11-5-18
pectors 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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
978 Main Street
Properly Address
Joseph Cerretani
Owner owners Name
information is Cotuit MA 02635 11-5-18
required for every
page. cityfrown 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:
® 1 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 2000 Gal. H-20 Tank-D Box and five chamber's.
2) System Conditionally Passes:
❑ One or more system components as described in the "Condltional 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 ❑ NO (Explain below):
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
r
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information Cotuit MA 02635 11-5-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumpslalarms 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 ❑ NO (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,
{ )( ) Y 9 P P
ub c
safety and the environment:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is required for every Cotuit MA 02635 11-5-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
❑ 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 wlthin
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.
Th❑ e system has a tic tank and SAS and the SAS is less than 100 feet but 50 Feet or
Ys septic
more from a private water supplywell
fk
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form,
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for alb,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
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I
c, Commonwealth of Massachusetts
. Title 5 Official Inspection For
m
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is required for every Cotuit MA 02635 11-5-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cost.)
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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'Y day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes If the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
Q ® 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.
S) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
ilonis
reequiredquired for every Cotuit MA 02635 11.5-18
page. cityrrown State Zip Code Date of Inspection
C. Inspection Summary (Cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must Indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as 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?
® 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)]
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owners Name
Information is required for every Cotuit MA 02635 11-5-18
page. Ctty/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.2C3(for example: 110 gpd x#of bedrooms): 550
Description:
Description:2000 Gal. H-20 Tank D Box and five chambers.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2016-140,000Gal
g ( y g (gpd)): 2017-185,000Gal's
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
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�0 Commonwealth of Massachusetts
. 1� Title 5 Official Inspection Form
N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is required for every Cotuit MA 02635 11-5-18
page. cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatslpersonslsq,ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Tile 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:
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
E
v 978 Main Street
Property Address
Joseph Cerretani
Owner Owners Name
information Is required for every Cotuit MA 02635 11-5-18
page, Cityffown State Zip Code Date of Inspection
D. System Information (cons.)
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(Altemative 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 11A 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:
1994 Permit # 93-639.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 6'
teat
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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is required for every Cotuit MA 02635 11-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade:
5'
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:
2000 Gal. Precast H-20
V.
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 29"
Scum thickness 0U
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 18
How were dimensions determined? Asbuilt-Plan-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 at 5' Below grade w/outlet cover at 4"below grade. Out let tee. No
sign of leakage or over loading.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is required for every Cotuit MA 02635 11-5-18
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 ❑polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
atl is required
for
Cotuit MA 02635 11-5-18 required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank cont.
g 9 (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comme
nts (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.):
Camera out to box. D Box is clean and solid. No sign of over loading
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0£ a5ed xed dH Z0:60 91,OZ 80 AON
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
4 Joseph Cerretani
Owner Owner's Name
information Cotuit MA 02635 11-5-18
required for every
page. Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 5
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
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I•£ abed HIJ dH Z0:60 860Z 80 AON
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' 'r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is required for every Cotuit MA 02635 11-5-18
page, City)Town state Zip Code Oate of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is 5 Galley's W12 stone.Ck D Box no sign of over loading.
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.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
I.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�,. 978 Main Street
Property Address
Joseph Cerretani
Owner Owners Name
information is required for every Cotuit MA 02635 11-5-18
page. Cityrrown 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.):
15insp.doc-rev.7126/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 18
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owners Name
information is Cotuit MA 02635 11-5-18
required for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cunt,)
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
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Commonwealth of Massachusatts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
978 Main Street
Property Address
Owner Owner's Name
Informrequired
Is Cotult MA 02635
required for every _,
page. Cityrrown State Zip Code Date or Inspection
D. System Information (cont.)
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
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t5fns.eo�•rev.6118 rAe 5 ONciel Inspeelian Form:Subsurface Sewage Disposal Syslem•page 15 or 11
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L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
( Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owners Name
Informn Is
required
Cotuit MA 02635 11-5-18
required for every
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
a�
Estimated depth tol5igh ground water: 28
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: 5-19-93
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:
T.H. on Desisign plan 5-19-93 no G.W. at 28d. Bottom of leaching at 10' below grade, Bottom of
leaching at 12'above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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o w
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
fv
` 978 Main Street
Property Address
Joseph Cerretani
Owner Owners Name
information is required for every Cotuit MA 02635 11-5-18
page, City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B,Certification: Signed &Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1,2, 3,or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
❑ D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
15insp.doc•rev.7/2612018 TIVe 5 Offlcia;Inspection Forth:Subsurlace Sewage Disposal System•Page 18 of 18
LE a5ed xed dH COW 8 M 80 AoN
�ttll "t 20 2016 22:44 Jim The Inspector Man 5085349919 page . 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r�
978 Main Street �7t
Property Address �.
Joseph Cerretani '
a
Owner Owner's Name, °�—
information Is required for.every Cotult MA 02635 10-18-16
page. Citylrown 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 ng o Aut forms . General Information �y
oinl the computer. S�# ��7 SRO `A��N OF►ISS
use only the tab 1. Inspector: • . . ''q�' �%
key to move your p s O? ' �G
cursor-do not James D.Sears =� JAMS ':m
use the return �'
Name of Inspector
key. Capewide Enterprises, LLC
rrrt+s`.
Company Name
153 Commercial Street i�� 15WwPt���``��`
Company Address
I Mashpee MA '02649
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
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 16.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
'r, 10-18-16
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 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.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r/
GD Y S
�9
Oct 20 2016 22:44 Jim The Inspector Man 5085349919 page 2
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani _
Owner Owner's Name
Information Is required for every Cotuit MA 02635 10-18-16
page. Cityrrown. State Zip Code Date of Inspection
B. Certification (cant.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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 2000 Gal. H-20 Tank- D Box and five chambers.
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.
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 exfiitration 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):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 " .
Oct 20 2016 22:44 Jim The Inspector Man 5085349919 page 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is required for every Cotuit MA 02635 10-18-16
.
page. Cityrrown Stale 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 (cont.):
Ll 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 ❑ NO (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
i
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 17
Oct 20 2016 22:44 Jim The Inspector Man 5085349919 page 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owners Name
Information is required for every Cotuit MA 02635 10-18-16
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board.of Health (and Public Water Supplier, If any)
determines that the system is functioning in a"manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1'of a public water
supply.
❑ The system,has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or .
more from a private water supply well".
Method used to determine distance:
*' 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
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 is less than 5"below invert or available volume is less
than '/2 day flow L F A C Wm
15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Oct 20 2016 22:44 Jim The Inspector Man 5085349919 page 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
978 Main-Street
Property Address
Joseph Cerretani
owner. Owners Name
information is required for every .Cotult MA 02635 10-18-16
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cost.)
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.
❑ ® 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 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 2000gpd-
10,000gpd.
❑ ® The system falls. 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 dunking water supply
El Elthe 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.
ISlns.doc•rev.6/16, - Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 5 of 17
Oct 20 2016 22:45 Jim The Inspector Man 5085349919 page 6
Commonwealth of Massachusetts
Iowa Title 5. Official Inspection Form
Subsurface Sewage Disposal ! Form -Not for Voluntary Assessments
rt 978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is Cotuit MA 02635 10-18-16
required for 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:
i
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
III
® ElWere all system components, excluding the SAS, located on site.'
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)(310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins.doc•rev.6116 Title 5 Official InSPOUIDn Form:Subsurface Sewage Disposal System•Pope 6.o117
Oct 20 .2016 22:45 Jim .The 'Inspector Man 5085349919 page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
VFW
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
978 Main Street
Property.Address
Joseph Cerretani
Owner Owner's Name
information is required for every Cotult MA 02635 10-18-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 2000 Gal. H-20 Tank D Box and five chamber's.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
2014-157,000Gal
Water meter readings, if available(last 2 years usage(gpd)): 2015-183,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commerciallindustrial 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,
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17
Oct 20 2016 22:45 Jim The Inspector Man 5085349919 page 8
Common wealth-of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
0 978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name i
information is required for every Cotuit MA 02635 10-18-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: pate
Other(describe below):
General Information
Pumping Records:
Source of information: 7/16115
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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):
15ins.doe-vv.6116 Title 5 Official Inspection Form:Subsurface Sawage Disposal System-Page 8 or 117
Oct 20 2016 22:45 Jim The Inspector Man 5085349919 page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owners Name
information is required for every Cotuit MA 02635 10-18-16
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1993 Permit#93 -639.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
6'
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.
Septic Tank (locate on site plan):
5'
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: 2000 Gal. Precast H-20
Sludge depth: 1
t5ins.doc•rev.6116 Title 5 Offidal Inspection Form:Subsuiace Sewage Disposal System-Page 9 of 17
i
Oct 20 2016 22:45 Jim The Inspector Man 5085349919 page 10
Commonwealth of Massachusetts t
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owners Name
information is 3
required for every Cotuit MA 02635 1 o-1 a-16
page. Cityrrown State Zip Code Date of inspection
D. System Information (coot.)
Septic Tank (cont,)
Distance from top of sludge to bottom of outlet tee or baffle
Zg"
011
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
18"
How were dimensions determined? Asbuilt- Plan -TapeSludge 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 at 5' below grade w/outlet cover at 4" below grade. Out let 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:
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
l5ins.doc•rev.6/16 1itle 5 Ofriclal Inspection Form.Subsurface Sewage Disposal System Page 10 of 17
Oct 20 2016 22:45 Jim The Inspector Man 5085349919 page 11
Commonwealth of Massachusetts
a
Title. 5 Official Inspection Form
R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is required for every Cotuit MA 02635 10-18-16
page. Cityrrown 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):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
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
t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurfeoe Sewage Disposal System•Page 11 of 17
Oct 20 2016 22:46 Jim The Inspector Man 5085349919 page 12
Commonwealth of Massachusetts
Title. 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information Is.
required for every, Cotuit MA 02635 10-18716
page. CityfTown State 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 a
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.):
Camera out to box. D box is clean and solid. No sign of over loading.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: El 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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
&rls.doc-rev.6/16 Title 5 official Inspection Form!Subsurface Sewage Disposal System Page 12 of 117
Oct 20 2016 22:46 Jim The Inspector Man 5085349919 page. 13
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments
x
978 Main Street
Properly Address t
Joseph Cerretani
Owner Owner's Name
information is required for every Cotuit MA 02635 10-18-16
page. CitylTown Slate Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
5
® 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.):
Leaching is 5 Galley's w/2' stone. Ck D Box no sign of over loading.
i
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.doc•rev.6116 Title 6 Official Inspection Form'Subsurface Sewage Disposal System•Page 13 of 17
Oct. 20 2016 22:46 Jim The Inspector Man 5085349919 page 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani _
Owner Owner's Name
information is required for every Cotuit MA 02635 10-18-16
page. City/Town State Zip Code Dale of Inspection
D. System Information (cont)
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.):
l5ins.doc•rev.6116 Tide 5 Official Inspection Form:Subsurface Sewdge Disposal System-Page 14 of 17
Oct 20 2016 22:46. Jim The Inspector Man 5085349919 page 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information Is Cotuit MA 02635 10-18-16
required for every —
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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
R
J- 1
4
d`�`
e j
0
i
�'1 � tN5T
t5lns.doc•rev.W16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Oct 20 2016. 22:46 Jim The Inspector Man 5085349919 page 16
i
I .
Commonwealth of Massachusetts
OMWOMM Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
information is Cotuit MA 02635 10-18-16.
required for every
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells 0
28'
Estimated.depth to high groundwater: 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: 5-19-93
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:
T.H. on Design plan 5-19-93 no G.W. at 28'. Bottom of leaching at 10' below grade. Bottom of
leaching at 12" above T H Depth
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.5116 TWe 5 Offloal Inspection rorm:Subsur`ace S9wage Disposal Sysiem•Page 16 of 17
Oct 20 2016 22:46 Jim The Inspector Man 5085349919 page 17
i
Commonwealth of Massachusetts -
- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
978 Main Street
Property Address
Joseph Cerretani
Owner Owner's Name
Information is required for every Cotuit MA 02635 10-18-16
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
t5ns.doc•rev.6116 - Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 17 of 17
�. TOWN OF BARNSTABLE
LOCATION 78 ,a/ sy SEWAGE # (�5�
VILLAGE (7(7Ti/t 1T ASSESSOR'S MAP & LOT
INSTALLER'S NAME &,PHONE NO. /fje.f« .
SEPTIC TANK CAPACITY -14 -2y
LEACHING FACILITY:(type) �NL.Ls-y (size) y
i
NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATE
BUILDERy,OR OWNER 6?et)il�r�
DATE PERMIT ISSUED: �17
DATE COMPLIANCE ISSUED: fs
VARIANCE GRANTED: Yes No
r
F
'YO
O
CoervzAw �-.
O t
t.
lvl eenn
No. - ......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
_�C>-\AAQ..................OF...
Appliratiun for Rapuual Workii Tomitrurtiun ramit
u P 6eP.P_ S
Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal
System at: 40
...................... •-•--•------------------------------------•-•---------••-•-•----------••---•••---.................
Location-Address ��'1 ` or Lot No.
�OS6�+4._.C-eif.R�.ET'A.n� ` ?bM �YV �
---- ------------------ ---- .....-----......------------......-•--------------------------------------------........_.----
owner Address
W
--- -------------------
Qa Installer Address
Type of DwellinBuilding
in No. of:'B Size Lot.1V.)_ R.5---------Sq. feet
edrooms____�7�...................................Expansion Attic ( ) Garbage Grinder (�(�
aOther—Type of Building ............................ No. of persons............... ( ) ( )
-- • -•-------------------•---•.................
a Showers Cafeteria
d Other fixtures
W Design Flow........50,7C)........................gallons per person per day. Total daily flow........5.'5-70......................gallons.
WSeptic Tank—Liquid capacity. allons Length---------------- Width................ Diameter................ Depth................
x Disposal Trench—No._._1............... Width...5............ Total Length..?-A_-.-.------ Total leaching area..44-......sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosin nk
~' Percolation Test Results Performed by... _.-).�.2_�............. Date... .' _:9 _..__.._.....
a
Test Pit No. I.._L2__--_minutes per inch Depth of Test Pit...,7............ Depth to ground water---
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --•---••--••-----------------------•-----•••-••••••••-•...-•-•----•---......--•------------.......--....................................................
0 Description of Soil.........®^'Z,Lr�,g _.�v .1.5�.._2-1 Z olVl-G 5A►'l)-Q -
x .._..
V ..................................•.......-•-•---•--•---•------•---•-••--•-------•--•----...-•-••-••--•••-•-•-------•-•-----••-•---••••-•-•----•-•--•-•-•••---•••---••-------------------------------••.
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
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 Comp,4 ce ha b�issued by the board of health.
Signed (,- ---------------------------------- ...................................
Application Approved By .......... ....... ...- ... .............. .---- - -*'. ..�
Dace
Application Disapproved for the following reasons- -------------------- ------ -......................................................................................................
------------------------------ ---- - --------------------------------------------------------------- ---- ------------------------------ .......................................................... ------------ -
�j ------------------------
Dace
PermitNo. ...... 3-- 6127------------------- Issued .......................................
Dace
No. .............�J� Fim..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
U----......__....OF.:........Et t...U
................. .................................................
Appliratiun for Disposal Works Toustrnr#iun rrntt#
U p bApr✓
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.... eta 1
Location-Address �� es or Lot No.
1? �.......... .. �..) ...........................................................
Owner Address
W
Installer Address
UType of Building Size Lot.-_--_a Sj ---------Sq. feet
Dwelling—No. of Bedrooms.-.J...................................Expansion Attic ( ) Garbage Grinder (9(�)
'4 Other—Type of Building ............... No. of persons......................_.._.. Showers — Cafeteria
Q' Other fixtures ------------------------------ -
e ���� D gallons
sp person per day daily flow
gallons.
Septic Tank—Liqudpacity.? llos Length Width- - Diamte> ._.. - Depth.•_ :
Disposal Trench—No. ...1............... Width... ............ Total Length..:�1....._..... Total leaching area--4.1.5...___.sq. ft.
3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosingnk
Percolation Test Results Performed by..... .-.'- _.............. Date.. = _: _ .............
a 1 p p 7 p ground 1dl o r
Test Pit No. 1..._..-._.-.....minutes er mch Depth of Test Pit._-t__::�_.__.___._. Depth to ound water..__..:....�.�.....
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....:..._......._.._...
P4 •---••-•--••-•-••----------•-•-•-•••--•-•-•-••---•-•••-•-••••-••-•--•............................•••.........................................................
0 Description of Soil---------DZLc A `'' 11- - 5 .....................................................
x
W --•--•-•-------------•--------------•----------------------------•••--•-•---------•-•--•-•-••-----••----•--------•--------------------------•----•---•--•---•----•----•--------••-----•-•--•---•........
UNature of Repairs or Alterations—Answer when applicable...............................................:...............................................
•-•-•••-••-•--•••------•--•••---•-•••••...........•--•---•••-----•••-••--•-•-•--•-•••--......•-•-------••-••-•-----•----•--•-----•-----•--••••---•--•-----------•-••••••--••-•----------•••••...........
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 ---------------------------------------------------------......................................------------ --- -- ---------------------------
Date
ApplicationApproved B C - ....... ... %...ea.,:. ><—_,-------------------------------------------------------------------------- :- ------?'3
Application Disapproved for the following reasons- ---- ------- -- - ----------------------------------- ---------- .................................... .............
...................... .---------.......------------------..........---...---...-----------------------........----...------------. .
D.
Permit No. _ Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�G.v... v OF _� \c�..l,..S- �_..L..........................................
Ger#ifi ate of Clontyliance ; J
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ------------------------------- ...------------------------------....................--------------------------------------........------------------------... -------------
at �7 MI� ' l � �.......
------.. - .. ......................................... ...
------------ --- - --- ---------------------------- ----------------- ------------------------------- --- .
has been installed in accordance with the provisions of TITLE 5 o£The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ......./.� ------ 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
OF.... ZiUS1 13C
�j ............................................ ..2
Disposal Works Tunufrndiun rrnti#
P,erlx�issiou
hereby granted..............................................................................................................................................
er�'"�r
to Construct C ) or Repair_( ) au Individual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction Permit No!-./__6,,.*?, .. Dated..........................................
•--------------------------------------------------------------------•---------......_.........__.....
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
7zd �c �—
TOWN OF BARNSTABLE
-V Q UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
ASSESSORS MAP NO. PARCEL NO.
n 71
ADDRESS: 9� 8 /�a,'� Sfi X �� VILLAGE
NAME!_ D Y_�D.�.....:__ . : r.OG✓K e., . ..� tr•
CONTACT PERSON 0-b o v e PHONE NUMBER
LOCATION OF TANKS:. CAPACITY: . TYPE OF FUEL. AGE: TYPE: LEAK
OR-' CHEMICAL: DETECTION
SYSTEM'
DATE OF PURCHASE OF EACH: 1. 7 2. 3.. 4. 5.
DATE OF• FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
WOV6
U = r
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.
-��
�'
` ��� v
II
KEEPING YOU ORGANIZED
No. 10334
2453Lo
(MADE W USA
CET ORGANIZED AT SMEA9.COM
5.8. FND. �l�� OYSr N
/— LACE ER
txbcus MAP
SCALE 1 ; 25,000
` ASSESSORSSCHOOL ST. >
LOCUS Q l
MAP 34 PARCEL 32
,k ZONE �� a
A.P. c,
HOUSE NO. 978 MAIN Si. BLUFF'
c(o ELEVATIONS BASED ON N.G.V.D. Pr
2000 GAL. F.F. ELEV. 43,06'
SEPTIC TANK _�. . �
' 24" P.C.C. RISERS BOTH ENDS INV - F.G. $O.O' F.G,- 40,0'
35.2I
s, s js3 ..
36.0
�- l HEAD' DUTY F& G ' '`` "�� � `� �.,�.�.�.._...-�- � _" INv. >a '
Aft 0 ELEV. = 40.0 F.G.-40.0' TO >" h �. 4 a B --- 8 PIPE � INTERNAL PLUMBING
1 FILE. 3 ,40 F r � I INN. — ►0 BE RESET.
IN 0a o o- ® D __.._ isv. = 35.6 iLOAM .
2 l
n 35.4'L_ ____ _°0a0°0 u 0 V r 0°ga0 3" PEASTONE
Ut}Q0 oaoa®�1 0�naa0 � �. '�
., ° ELEV. — 31.0 SET D. 130X CAN 6" DEEP
MEDIUM 2.0' K, 3/4" -- 1 1//2" 2,0'i CRUSHED STONE BASE,
SAND r� WASHED STONE r— ! ,
z 4'X 4' LEACH GALLIE'S
0 12 ELEV. == 28.0' 04
Cd \�� NO WATER in
,
.1 C.B. FND. \�0 O
DESIGN DATA
o F )\ Sto �� _ _ U 5-� 4�` 4 .20 L .CHA .G �_,S EXI.�I iNG SINGLE FAMILY .5- BEDROOMS
i C.S. FND. \ �/ he dWITH 2' X 4' OF S ONT1, ON THE SIDEES NO GARBAGE GRINDER
72 wide SIDE' AU. AREA w 4X64X2e5 640 GA /DAY DAILY POW - 110 X 5 " 550 G.P.D.
F, BOTTOM AREA SX24-X1e0 192 GAL./DAY SEPTIC TANK -� . 50 X 150r. m E25 G.P.D.
�F` ( TOTAL DESIGNI 832 GAL. DAY USE VI-2-0 Z GAL. SEPTIC TAINK
' F c
250 RULE DOES NOT APPLY FOR YiE
`.P.&FND. < 6 PERCOLATION RATE: CAN PROVIDE MORE FIAN 14' ABOVE
0
oaf \ o�0r' i INCH IN 2 MINUTES OR LESS. GROUND NATER TO BOTTO j OF SYSTE M,
t
OTC °� 3
f
C.E�3 FNC�%
I
�.
° °�
0
;) C, °
pe \
I &N
I v
O
SCALE; 1'"' 20' �� C S� 95
GRAPHIC SCALE
0 10 20 40 k- oy or
B D���ti
N �
(0C M S W G
PAIM 3
PLAN OF LAND
\
I�`t' - �Cv tJ
IN \
(C O TU I T)
EMAt o r
--- paT1fZ_-8irt.Du1 2 *i /
o o
BARM!"ShTABLE MASS. A. .
FOR h\ CO
JOS'E So CER RuETANI 24.0' �t`w: I I ` o ca
bench mark 1 a
o' •vvv••v••vv•vvvvvvvv �►• el. — 35.71`
SCALE: 1 = 20 DATE: SEPT. 22 1993 •• �x v --� T sv• C.B. FND.
REV. SEPT. 28,1993 2'0' 5 41X 4' BEF, h : oo /
♦♦ vv•v•v••••vvvvvvvI w!• /
BAXTER--& NYE INC.
REGISTEROD LAND SURVEYORS o
CIVIL ENGII`iEERS N WASHES
OSTERVILLE, MASS. STONE
li OF
v M
VOWAM
PETER C. r NO SCALJE .
o SULLIVAN NYEi
No. 29733 " `No. 19s34�o a
,pp
jsTl�
O,, GIST6��O
FSS�ONAL
NOTE: THE PROPERTY LINE AS SHOWN ON THIS PLAN 'f$ BASED ON ORIGINAL DEED DIMENTIONS
AND GROUND CONTROL EVIDENCE, AND CONTRADICTS SOME INFORMATION SHOWN ON PLANS
DEED REFERENCE: BOOK 890 PAGE 409
RECORDED BOOK 111 PAGE 97 AND BOOK 117 PAGE-139.
93103