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Commonwealth of Massachusetts 03�-d3(p
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ':a
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............ ,» 994 Main Street
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Property Address ?
Michael Schulz- �•"
Owner Owner's Npe
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information is ='
required for every Cotuit I Ma. 02635 08-02-2019
page. City/Town i State Zip Code Date of Inspection
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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 filling out forms A. Inspector Information
on the computer,
use only the tab Michael.T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
(► � 52 Rivers End Road
ITV Company Address
Teaticket Ma. 02536
City/Town State Zip Code
r 508-280-3356 S13938
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
- 4-2019
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
' in the future under the same or different conditions of use.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. 994 Main Street
u
Property Address
Michael Schulz
Owner Owner's Name
information is required for every Cotuit Ma. 02635 08-02-2019
.
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This 4 bedroom home has a 1000 gallon septic tank and a D-Box feeding a precast leaching pit. At
the time of the inspection there were no visible signs of system failure criteria.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board-of,
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
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7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u�
994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is required for every Cotuit Ma. 02635 08-02-2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval;if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑, Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is required for every Cotuit Ma. 02635 08-02-2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You,must indicate"Yes" or"No" to each of the following for all inspections: !
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
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f
Commonwealth of Massachusetts
�� .. Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;
u
994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is required for every Cotuit Ma. 02635 08-02-2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well .
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 994 Main Street .
u—
Property Address
Michael Schulz
Owner Owner's Name
information is Cotuit Ma. 02635 08-02-2019
required for every
page. Citylrown 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?
I
❑ ® 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 i
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?
I ® ❑ Were all system components, excluding the SAS, located on site?
I
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank j
inspected for the condition of the baffles or tees, material of construction, j
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 j
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
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® ❑ 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 ►
a Title 5 Official Inspection Form '
I
ii; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;
994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is required for every Cotuit Ma. 02635 08-02-2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
i
Number of bedrooms (design): 3 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus gpd
Description:
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Number of current residents: 0
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Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to: I
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Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No
information in this report.)
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Laundry system inspected? ❑ Yes ® No '
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Seasonaluse? ® Yes ❑ No j
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Water meter readings, if available (last 2 years usage(gpd)): !
Detail
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Sump pump? ❑ Yes ® No
July 2019,
i Last date of occupancy:
Date
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3 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ala Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is Cotuit Ma. 02635 08-02-2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
s 2. Commercial/Industrial Flow Conditions:
4 Type of Establishment: i
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
b1 Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
i
If yes, discharges to: y
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
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Last date of occupancy/use: Date
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Other(describe below):
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3. Pumping Records: j
Source of information:
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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I
Commonwealth of Massachusetts
e, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L,—
994 Main Street
Property Address
a Michael Schulz
Owner Owner's Name
information is Cotuit Ma. 02635 08-02-2019 I
required for every; �
page. a City/Town State Zip Code Date of Inspection
D. System Information (cont.)
t 4. Type of System:
i ® Septic tank, distribution box, soil absorption system
t
t ❑ Single cesspool
r
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1987
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
6'
Depth below grade: feet
Material of construction:
i
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water
feet
I
q Comments (on condition of joints, venting, evidence of leakage, etc.):
II
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 !
Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
I
994 Main Street
Property Address
1
Michael Schulz j
Owner Owner's Name j
information is required for every Cotuit Ma. 02635 08-02-2019
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: ?
feet
Material of construction:
® concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
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If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ ,Yes ❑ No
standard 1000 gallon
Dimensions:
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness
2" I �
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Distance from top of scum to top of outlet tee or baffle
4" I
Distance from bottom of scum to bottom of outlet tee or baffle
16" �
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sludge judge j
How were dimensions determined? I
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At the time of the inspection the liquid level was at working level and the baffles were in place.
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t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
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c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I? la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
994 Main Street i
u� Property Address
Michael Schulz
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 08-02-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
l:
Depth below grade: feet
i
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
I
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.):
P
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8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
I Material of construction:
l ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
i 4
a
Dimensions: f
Capacity: gallons
Design Flow:
gallons per day e
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 4
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is Cotuit Ma. 02635 08-02-2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
I
8. Tight or Holding Tank(cont.)
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Alarm present: ❑ Yes ❑ No
f Alarm level: Alarm in working
order: El Yes ❑ No?
? Date of last pumping: Date i
i Comments (condition of alarm and float switches, etc.):
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*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ Nod
9. Distribution Box(if present must be opened) (locate on site plan):
I Oil
Depth of liquid level above outlet invert
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.):
At the time of the inspection there were no visible signs of leakage.
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
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Commonwealth of Massachusetts
(a' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v—
i; 994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is Cotuit Ma. 02635 08-02-2019
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
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* 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:
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Type:
+ ® leaching pits number: one
❑ leaching chambers number:
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❑ leaching galleries number:
e
❑ leaching trenches number, length:
g
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
! ❑ innovative/alternative system
Type/name of technology:
t5insp�doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.;, 994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is required for every Cotuit Ma. 02635 08-02-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
I
11. Soil Absorption System (SAS) (cont.) i
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Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition oI
vegetation, etc.):
At the time of the inspection the leaching pit was dry.
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12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
r.
Number and configuration
Depth—top of liquid to inlet invert i
Depth of solids layer
k
5
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.): l
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ala Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is Cotuit Ma. 02635 08-02-2019
required for every `
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
a
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Materials of construction:
Dimensions `
Depth of solids
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Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 3
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
994 Main Street
Property Address
Michael Schulz
Owner Owner's Name
information is required for every Cotuit Ma. 02635 08-02-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference.
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below: }
❑ hand-sketch in the area below I;
` ® drawing attached separately I
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TOWN OF BARNSTABLE:
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LOCATION L c:7l �s.s>� 'f .: SEWAGE
VILLAGE
Crt T - ASSESSOR'S MAP St LOT`
k INSTALLER'S NAME& PHONE NO. 9,z F� (3,Y S,T'
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ! C.1j hi i' (size) 6 0 6,9
NO.OF BEDROOMS 3 PRIVATE'WELL OR PUBLIC WATER
• BUILDER OR OWNER v2 J
DATE PERMIT ISSUED: / . .
DATE ;COUPI;IANCEISSUEU:
VARIANCE GRANTED: Yes No I'
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Commonwealth of Massachusetts ` l
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
994 Main Street
Property Address t i
i
Michael Schulz -
Owner Owner's Name
information is required for every Cotuit Ma. 02635 08-02-2019
page. City/Town State Zip Code Date of Inspection f
D. System Information cont. I%
y (cont.)
15. Site Exam:
® Check Slope
® Surface water i
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® Check cellar !
® Shallow wells
16 plus feet i
Estimated depth to high ground water: feet II
Please indicate all methods used to determine the high ground water elevation:
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❑ Obtained from system design plans on record li
If checked, date of design plan reviewed: Date
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® Observed site(abutting property/observation hole within 150 feet of SAS) i
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❑ Checked with local Board of Health -explain: i
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❑ Checked with local excavators, installers-(attach documentation)
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❑ Accessed USGS database-explain:
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You must describe how you established the high ground water elevation:
I augered a hole at a lower elevation and I shot it with a transit to show 4 plus feet of seperation.
)
x
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d
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
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I
Commonwealth of Massachusetts
IF
Title 5 Official Inspection Form '
�-
11 Subsurface Sewage Disposal System Form Not for Voluntary Assessments �
............. !% 994 Main Street
V
Property Address 1
Michael Schulz !
Owner Owner's Name
information is required for every Cotuit Ma. 02635 08-02-2019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of: i
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked l
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
i
4 (Failure Criteria) and 6 (Checklist) completed Ii
II
® D. System Information:
i
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
I`
For 15: Explanation of estimated depth to high groundwater included i
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t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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Tr • 1
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
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.
A. General Information
I II � .
1. Inspector:
III"''�61V III /r
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433
Telephone 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 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Alf-
3/28/14
Inspector'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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Y rk
V
994 Main St.-03/08 Title 5 Official on Form:Subsurface Sewage Disposal System•Page 1 of 15
t t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
994 Main St
Property Address
Wall
Owners Name
Cotuit MA 02635 3/28/14
Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Pumping suggested every 3 yrs to prolong the life of the system
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
' A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
n/a
❑ 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
❑ obstruction is removed
994 Main St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Mt 994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cunt.):
❑ distribution box is leveled or replaced
ND Explain: '
n/a
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
n/a
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
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.
994 Main St.•03/08 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
994 Main St
Property Address
wall
Owner's Name
Cotuit MA 02635 3/28/14
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
n/a
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 cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
994 Main St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 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 fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ 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.
994 Main St.-03/09 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
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?
❑ ® 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?
® ❑ 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)]
994 Main St.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
City/Town State Zip Code Date of Inspection
D. System Information
Residential flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . 440
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage 363 GPD
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: seasonal
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: n/a
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:
f Last date of occupancy/use:
Date
Other(describe): n/a
994 Main St.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: No history given
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):
Approximate age of all components, date installed (if known) and source of information:
1987 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
994 Main St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
8'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 716"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-20 tank, inlet cover raised to 12"of grade
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000g
Sludge depth: trace
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle
>21'
>211
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measured
994 Main St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
4 . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y( 994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
Cityfrown 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.):
Pumping suggested every 3 yrs to prolong the life of the system
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
n/a
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.):
n/a
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):
n/a
994 Main St.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
't 994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions: .
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
n/a
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Video inspected and appears to be in average condition for its age
r
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
994 Main St.•03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
E
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�< 994 Main St
Property Address
wall
Owner's Name
Cotuit MA 02635 3/28/14
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
I
Soil Absorption System (SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ leaching chambers ' number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool - number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit has steel cover raised to 6"of grade, it has 1'of effluent in it at this time, stain line 6"below
inlet invert, no indication of backup
994 Main St.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
n/a
994 Main St.-03108 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a( 994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
6D
994 Main St.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
994 Main St
Property Address
Wall
Owner's Name
Cotuit MA 02635 3/28/14
City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: >20'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:.
Per elevation of home
994 Main St.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
li
TOWN OF BARNSTABLE
LOCATION L re 7' A i 'All 57`7- 3 .
SEWAGE # � 7 7 ;2-`
VILLAGE Ce,,7-t,
ASSESSOR'S MAP Cz LOT
INSTALLER'S NAME & PHONE NO. /lv24 ,Y
SEPTIC TANK CAPACITY / ® lit ,
LEACHING FACILITY:(type) 4-1 4- C. (size) -1,,,-0 0 6,
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER A,94Z
BUILDER OR OWNER Jc� /�,v / ��c �.9 �•2 GZ Y t
DATE PERMIT ISSUED:
DATE COLiPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�,�;
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
....To1rJN- ...........oF.....bW- W5-_T.V.t----------------------------------------
Appliratiun for Diipuual Works Tunitrurtiun Pprutit
Application is hereby made for a Permit to Construct (Xor Repair ( ) an Individual Sewage Disposal
System'at:
.1. Q.-T:.A..._.0.tt...r1Nw...5zr.�rT............ ......................• ...... .............................................
V _VW
---•------- --------------------------•----- Lot No.
...... Address
Installer Address
Type of Building Size Lot_11,10G.±-.-Sq. feet
V Dwelling—No. of Bedrooms_._.......�................ .....Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons..........CO............. Showers — Cafeteria
a' Other fixtu es ............................
w Design Flow...............5..-••.....................gallons per person per day. Total dail flow......5�0.......................gallons.
WSeptic Tank—Liquid capacity-gallons Length_6nra.„.. Width.�'_lon' Diameter................ Depth..5'•4_-.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.______�__._______. Diameter._1.�_"0.... Depth below inlet....._�4_.......... Total leaching area...?.�'..51...sq. ft.
Z Other Distribution box (�) Dosing tank 4 ) A
Percolation Test Results Performed by-CAM_ F.15�41 ._.
a
,.a Test Pit No. 1................minutes per inch Depth of Test Pit----15 _... Depth to ground water---------GO.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R.' - -•-•---•------•-•-• - R
Description of Soil........... LUM..... /U�-•-•-- -� ....• ---------------------------------•-•-----.-•---
x
w
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
-----------------------------------------------•--------------------------------------•------------------......---------------------------------------•------------•-------------------....•-----......
f Agreement:
- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi U 5 of the State Sanitary ode— The signed further agrees not to place the system in
operation until a Certifi of plian ee t e bo d of health.
s �143
>g- ---•-•-- --�
-7
• Date
Application Approved By......__ .......................
_____. _ .._ _ .. .._______.. .................
Date
Application Disapproved for the following reasons-----------------------------•---------------•--.•--•-•.........1......................----•----------.........•
-•-----------------------------------•--...--•--...-----------.......---•-•-----------.....-•-------•------••-••.....•••••••----•••----•••••----•••••-••--••-••••--••-••--.. -----............--._..
-L D,ate .
Permit No...... --• ...................... Issued-...............
4
Fing........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TW-W.................OF..... .........................................
Appliration for Disposal Works foustrudion Frrutit
Application is hereby made for a Permit to Construct: ( Xor Repair an Individual Sewage Disposal
System at 4. i
LQ_-r..A......Qtt...NA-it4...5-T-att-i............ ....................... .............................................
Location-Address or Lot No.
Pk ..........................................
j
........ .......... ...................................................... ........................................................
�W(
w
...... ........................................... Address
.......................................................
.....4nst.lkr Address
Type of Building Size LotXLY_W.._-_'-._Sq. feet
U Dwelling—No. of Bedrooms---........t............................Expansion Attic Garbage Grinder (
Other—Type of Building ............................ No. of persons...._....... ............. Showers Cafeteria (
P4Other fixtures ......................................................................................................................................................
Design Flow................7P_-�J....................gallons per person per day. Total daily flow.......5.5.0.......................gallons.
Septic Tank—Liquid capacity.10M.gallons Length.b.'.O.'.�_. Width.4.-10"Diameter---------------- Depth...
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No..._...I............I............. Diameter.1Z....(D...1. Depth below inlet......(4?......... Total leaching area...5_5_4D..sq. ft.
Z Other Distribution box ( V) Dosing tank ( .)
Percolation Test Results Performed by.f_,.A4'.tA_.125LA�A Date..ALh:7+..
Test Pit No. I.......Z......minutesperinch Depth of Test Pit.....(. Depth to ground water.._._._—....___.
Test Pit No. 2................minutes per inch Depth of Test Pit..__._..........__.. Depth to ground water........._..........___.
..................
-6 6----------------*...................................................*--------------------------
P4 ..r
0 Description of Soil.........._ .......... &�o..... jtw(,�.......ZA"
x
.........................................................................................................................................................................................................
U
................................................................................................. -----------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed In e:wage Disposal System in accordance with
the provisions of T I T 1Z- 5 of the State Sanitary od e undersi ed further agrees not to place the system in
operation until a Certifi., of C a an pli — en i ed y e bo " f health.
plian
7
b.
-Signed.
, .. ... .... ...... ....................... ..... ...... ......Date
ApplicationApproved By...............()�t�. . . ....)_—)............................ ... ... ........ ....................Date.- ..............
Application Disapproved for the following reasons:..............................................................................................................
.......................................................................................................................................................................................................
Date
PermitNo.....-9 --... ---------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... ..............OF.......... J*122.q.......................................
� Trrtifiratr of Tompliana
THIS IS TO CERT t the Individual Sewage DWiosal System constructed,*) or Repaired�,F Y, Tha
t
e C'
by----- —�......IN............w.............................................................................
staller
at.................... 14A ------I.Lm........51.1..................................................................................................
has been installed in accord�a_`ncewi the provisions of TIT Z _,5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..__.._C) dated_.............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............................:5... ..................... Inspector............ ...............................................
---- --- ---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ...... ..........OF............ ................................. FEE.......: 5�._..-
1-e ---AI
Disposa Work onstrurtion rrrudl
C
.....A....................................Permission is hereby granted__......:... ... .......... .................... .. .......................
to Construct (>r or Repair an I ividual Sewage Disposal yst
-------- -----
dividn Sewage
7m e Disposal y
at No.............4—.o.T..A........ Al I
.............. .. ............. ... .......
Street ..................
as shown on the application for Disposal Works Construction Permit No-V ....... Date .....................
7,
.......................................................................................................
Board of Health
DATE.' ...........
......................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS,.
AsBuilt Page 1 of I
TOWN OIL BARNSTABLE
LOCATION 104 i �y S SEWAGE # u 7 3
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. /1�''-e // j r 7 7-5
SEPTIC TANK CAPACITY_ / G E;�c. A
LEACHING FACILITY:(type)_L%A) L /i T (size) 6 47` 671 �
NO. OF BEDROOMS -3 PRIVATE WELL OR PUBLIC WATER 44
BUILDER OR OWNER
DATE PERMIT ISSUED: / 2 J ," 7
DATE COUPLIANCE ISSUED;
VARIANCE GRANTED: Yes No
�4
i
http://issgl2/intranet/`propdata/prebuilt.aspx?mappar=034036&seq=2 3/28/2014
S YS TEM PROFILE
NOT TO SCALE
' TOP FON. '
. 2 9. FINISH GRADE Zr . 5 FINISH GRADE OVER
:o:.gee::°: FINISH GRADE Ou'ER DIST. BOX ZC.4 FINISH GRADE OVER
SEPTIC TANK ZG. LEACHING PIT
?:o VARIES /
3" OF 1/8" — 1/2" PRECAST CONC. OR
12" MAX
�. O;:d ' o :ea o.:'.e a.b:..:e: •. .o.'. e: a. e;ca•O,•e;i •:°
:o. :d•.. e.
;ob ;•o;-0: :� ASHED PEA STONE
BRICK 6 MORTAR
311
e OUTLET PIPE LEVEL TO 12" BELOW GRADE
o.: p FOR 2 FT. MIN.
c .o •e
40
p L I Z�/ e:::! i..'o••.: o:•..o o , �•D o p°D: e.►.
C. I. OR PVC TEES 21 21 21 .04
o q�
.�' O 'p' I '7 e •S. .01
BSMT. FIR. o Q' �oQQ Gr�LLON
DIS TRIBU TION BOX
EL . ZZ .2 o.. • . p. �; .•.
, �- a INSTALL ON LEVEL BASE 3/4" TO 1-1/2" e
�, e . PRECA S. CC;NCRET�.. a WASHED a PRECAST a
° c,.o•,e.:o..: s' H—Z0 RL`-FIN ED o
CONCRETE
CRUSHED a
a. STONE' i
e.p.o• yao-o';o',..e:e••:o':o;•'.$.e:o•.'p• :� Q •e:.::.�•::d. 'o.• 'e o':o: I. :e :e. O•:
� /, .b;,o;•o. :.o.v e.o:o,'0•.°.» o.,•o••o,•,e.a'•,o,a e•:o•e•.• .o..P;..o•b:°• .
Y H—ZO REINF.
S Il d e:
S ZI . 7� SEPTIC TA .D• o:�O;l
INSTALL ON LEVEL BASE '+ •° ° °..Q. •'�
NOTE.' EXCA VA TE TO EL _ OR °.°. • o' o o o
LOWER TO REMOVE ALL IMPERVIOUS
MA TERIAL BENEA TH THE L EA CHING APEA 3 '-0 " 3 '—0 "
REPLACE EXCA VA TED MA TERIAL WI TH 6 ' 0 "
LOT �j CLEAN, CLA Y FREE SAND 12 ,-0 „
ago PA12C�L a EFFECTIVE DIAMETER !0 Z
� B Ni r p
EL 32. G 9 MSL
PRECAST CONCRET: L EA CHI�'G PIT LEACHINE: PIT
-.— yA
c� GENERAL NOTES
INSTALL ON. Lt V�"L', BASE
F
r.
32 1. AL!: ELEVATIONS SHOWN ARE 3A.,En ON M. S. L . T� F
I?OT M Q _ FL. 13.3 '
r L P1`PES IN ?:-/E ' YS`TF,ti1 :+MUST BE CA IRON O�SE tATi:7N PIT
-
y
SCNEDL L E r=r'". T ODD DER VA TION PIT ..,
t _
1 HE' EDARD OF HEALTH MUST 3E 'Ni�TIFIED _ _ • -
iV CONS TION` IS COMPLETE PAilOR
PRECAST L:JNCRETE HEN ,
SEPTIC TANK TO BA CKFIL L ING PERCOL A TION RA TE.'
4. ANY CHANGES IN THIS PLAN MUST BE APPROVED 2 MIN./IN.
BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS WITNESSED BY.'
SURVEYING CO., INC. G. DUNNING
5, MA TERIALS AND INS TALLA TION SHALL BE IN
COMPLIANCE WI TH THE STA TE SA NI TARP9ARN. BAD. OF HEAL TH DESIGN DA TA
CODE — TITLE V — AND LOCAL APPLICABLE DA TE.' A llGs �7,_,1987
RULES AND REGULATIONS °
F BEDROOMS
�_ �Cc;; NUMBER O —�
ON � ;� ) )\.� 6. NORTH ARROW IS FROM RECORD PLANS AND L " 2 GARBAGE DISPOSAL NO
IS NOT TO BE USED FOR SOLAR PURPOSES TOPSOIL 7. FLOOD HAZARD ZONE C SUBSOIL 6 DAILY FLOW 330 GAL .
`�,\ '/--- B. WA TER SUPPLY TOWN WA TER 2�7" SEPTIC TANK REO 'D. ?000 GAL .
sr SEPTIC TANK PROVIDED 1000 GAL .
At2CE-L G2 A
LEACHING REQUIRED 330 G D.
:X
MEDIUM
DRYWELLS FOR ROOF Ate. �� / \\ XI��TIt\lC� �TA112WAY SAND SIDEWALL AREA
RUNOFF (5 REO T.
-J35S:F.X 2. 5 G/S.F. - 33'1GPD
- BOTTOM AREA = L r 3 S.F
LEGEND __ -�-S:F:X_ : 0 G/S.F.= I i 3:GP0
LEACHING PROVIDED 4 50 GPD
PROPOSED EL EVA TION NO GROUND WA TER EL 10S.'S
256''
—— Z G—- EXIS TING CONTOUR HOUSE REBUILDING & SEPTIC SYSTEM UPDATE
�7__ Lo-r & OBSERVA TION PIT
CA12C L—L 3 G.� D DISTRIBUTION BOXIll �� of M '
A DOUBLE ROW OF HAYBALES TO BE PLACE 12, Zcp±c�F ���� Assq� ,, PROPOSED SEW GE DISPOSA L S YS TEM
o RICHARD
STAKED, 6 MAINTAINED ti
DURING CONSTRUCTION �� �O OO LEACHING PIT _ BERTRAND t
O a �j; PREPARED FOR
g �d No. 29894
VP A�o� F^ISTEP � PA TRI CIA Mc GA RR Y
Q/ o o SEPTIC TANK F ��
CXISTINCr 57WV_Wi-,,Y ss vA
A1.1D pLAT..C`OIZM tR?l RESERVE , A`�H �� �sf� LOT A OFF MAIN STREET
q ` COTUI T — BARNSTABLE — MASS.
DAVID �G\
o CHARLES `�1r'��
PIPE INVERT EL EVA TION SANICKI
E;7 $ 28085 DA TE.'SE-p. 14, 1561 CAPE 6 ISLANDS SURVEYING, INC.
PLOT PLAN � �s '�F�JsT�e,�° a
3 A ��^III ��N� SCALE A S NOTED P. 0. BOX 334
SCALE.' 1 "= 2p PLAN NO. S 20081 TEA TICKET, MASS.
MAP SEC PCL LOT HSE 4