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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
F992 Main Street
cotult _
A= 034 - 036 -
• ^'`^•-�._. i1.,,r•-�+-,�..-.._y,w....�.. •*!v'�"`^.r4..,-..-.-..n,..._ ....�......��"+�..^`Yn"�.i.J`Tsr�,,-^'.-_ �t-.-� ... ... r,,,,,,ni`v-....',K+..-"r.ti,.Y..... -:.•.-1+�-••..r -.r.-»•_
i
N / l �
THE CO MONWEALTH OF MASSACHUSETTS Entered in computer:
I� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s
Yicatfon for i onl�� � � *p.5temc Conf;tructtou Permit'
Application for a Permit to Construct( Repair� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. y m/'a i W S T_ ro-C-tel owner's
Name,Address,and Tel.No. m R C PR 61 �
Assessor's Map/Parcel Coo _u f?
Installer's Name,Address,and Tel.No. P V RO )(, 116 7 Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ,� U gpd Design flow provided 3 3 O gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank I S-6 V Type of S.A.S. a S-ZG CA1101, CLj AA ACi f
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) _ o 6 U o CIAa
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board !of Healt
Signed ,� it_.. Date
Application Approved by ?144 Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
T"-"'�•!:1� ., � :... � //{/ ^i / � � ]e�yy��'/)7)+)�y/1 ..:_-r.,.,TM._nirp, :� ' v ..� s r� , t.f; 'i.. ,4.�. . --.—.
-�� .-. �.�i/ ,l d. ! `��• /I li/1'(�J—J�C-'`y\, k�4 1 � ` �� r �*..
NoyV �' Fee
X!__VHE'C`bMMONWEALTH OF MASSACHUSETTS 4 Entered in computer:
PUBLIC HEALTH'DIV9ISION.:-DOWN OF BARNS TABLE, MASSACHUSETTS
1� lication for gtem ont * Congtructio�p , � 9� p n Verrntt
Application for a Permit to Construct O Repair w) Upgrade O Abandon O ❑ Complete System Individual Components
Location Address or Lot No:q p, r!co co LT`Owwnei,s Name,Address,and Tel.No. /J
Assessor's Map/Parcel b ( + -/ ( d� j') �( 'S r
Installer's Name,Address,and Tel.No. 1�0 K t16 7 Designer's Name,Address and Tel.no. a
/ G I;q�tily V14 Rnlh�461•
Type of Building:
Dwelling No.of Bedrooms Lot Sizes sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers(. ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 3 3 O gpd
Plan Date Number of sheets Revision Date
Title r
Size of Septic Tank / 5 6 V Type of S.A.S.' 570 Cht l Gu c ti h:_k-h Z
Description of Soil ''
Nature of Repairs or Alter
tions(Answer when
/applicable) r � li
_� // f/�u d IL -1 o(�(K��ar �o.
b B a K �60 CA�(�N. IfA d l t'e r4o& ( PA t•'
Date last inspected:
Agreement: i
c
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board f Healt
Signed !/ ,. �ti �t - Date (�
Application Approved by 1 c J� Date
Application Disapproved by: Date
for the following reasons
7
Permit No. Date Issued '
—————————————————————————————— —— —————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance —�
THIS'IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( )
Abandoned( )by h n, S u,/ u Kt 1 f 'aff 4
at oZ yl t ti S-1 ('�, y�'� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. r� dated �}
Installer&Lf-I Vr A c�,,��rS Designer—Cl,P h, A)
#bedrooms Approved design flow U i ni/ ) z gpd
The issuance of this permit shall n I e co�tred�as J guarantee that the system w l functi/o/n as design/ed�!
Date �/ Inspector f /1 / 0� '�fL/ !✓I��Lt /i �
_—___f�---
` --/l—_ ——.— ————— -------``— J—/—/�J ————
No. QC l V � Fee D�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Digogal 6pgtem Co truction permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this pe ft.
Date Approved by
V
Town of Barnstable
.�" .� Regulatory Services
Thomas F. Geiler,Director
* sniwstna�. -
b�, ]Public Healtb Division
039 Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: / Z`I L7 Sewage Permit# A��MjAssessorls MaplParcel O 3 Y o-75
Designer: C (ta ;`p f v••,/2.S Installer:
Address: 9 L c d4 fZos-eJ L a c,�,e Address: Pb 6'r—
On was issued a permit to install a
(date) (installer)
septic system at ql� Z 1k'ta,_,f 4- 40 based on a design drawn by
(address)
dated Oct I ro Z oy6
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Re uI tions. Plan revision or
certified as-built by designer to follow.
OF MASS9,
o� GLEN oyGN
ERIC
V's n )( g re 0 ;:
No.1070
O
S�FGIS't�PP
/TAB.
(Designer's Si ture (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU
Q:Health/Septic/Designer Certification Form 3-26-04.doc
Town of Barnstable P# 1 y l 3
Departinent of Regulatory Services I 1 1
? a Public Health Division Date l �p
aAsa 200 Main Street,Hyannis MA 0Z601
/ i d
.Date.Scheduled �O < �o Time ! ; Fee Pd. 1
Soil Suitability Assessment for Sewage D sposal
Performed By: 16,0E, /l� MlA, /e Witnessed By:
LOCATION&GENERAL INFORMATION
Location Address ,^ Owner's Name 4e rvi r
Address
! neer's Name (,./tr,E. h�a r•'i + .
Assessor's MapTarcel: 2 ` J ��( En b'i
NEW CONSTRUCTION •7 /REPAIR r ' o Telephone#
Land Use iwJ f " -Or k Slopes m 7 Surface Stones ��/�
Distances from: Open Water Body 7/-r9 ft Possible Wet-Area /i� 8 Drinking Water Well /7r ft
Drainage Way- —ft. Property Line /O ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
S
Parent material(geologic) ctiI�iO Depth to Bedrock
'V rj H� weeping from Pit Pace �O
Depth to Groundwater. Standing Water in Hole: r P $ l
Estimated Seasonal High Groundwater !li O •� 1 3`t �y '~ u�/
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used In, De th to soil mottles: in.
Depth Observed standing in obs.hole: p
Depth to weeping from side of obs.hole: in, Groundwater Adjustment
Index Well# Reading Date: Index Well level.... Adj.factor Adj.Groundwater Level
PERCOLATION TEST Ditto Tim
Observation Time at 9"
Hole#
Depth of Pere 2 -Time at 6"`'010
Start Pre-soak Time @
End Pre-soak
Rate Min./Inch' Z
Site Suitability Assessment: Site Passed Site.-Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back---
***If percolation test is to be conducted within 100'of wetland,you must first notify the.
Barnstable Conseirvation Division at least one(1)week prior to beginning.
Q:SEPTIGIPERCFORM.DOC
R
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soii Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
D •ll ,•/.
to leY4
to ! F--� Saved . !� Y2 6 Iva ,�cob�t'.o
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
s'
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soii Color. Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones,Boulders.
DEEP OBSERVATION11 LE LOG'' Hole#
Depth from Soil Horizon Soil Texture Soil Color
Soil other
(USDA) (Munstsll) Mottling (Structure,Stones;Boulders.
Surface(in.)
Y
Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No Yes
Within l00 year flood boundary No— Yes :—
De th of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material oxist in all areas observed throughout the
area proposed for the soil absorption system? V�
If not,what is the depth of naturally Occurring pervious material?
Certification
I certify that on 1 C 9 s (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
,expertise and en nce described in 310 CMR 15.017.
the required trainin
Signature
C- � Date
Q:\SEpTIMRCFORM•DOC
°F 'y� t.Lotuit ,Fire Mif�trict
CoTurr Water Mepartment
l 19i6 �9 4300 FALMOUTH ROAD, P.O. BOX 451
dU COTUIT, MASS. 02635 r
PHONE (508) 428-2687
FAX (508) 428-7517
::;_Donna Miorandy
Town_of Bar-nstable .
Board of Health
March 5, 2007
I met with Glen Harrington at 992 Main Street Cotuit, Ma. and reviewed anew septic
plan. I have no problem with them installing a membrane for the purpose of separating
the water service from the septic system as the plan stated. If you have any questions I
can be reached at 508-428-2687.
Chris Wiseman
121
Superintendent
Cotuit Water Dept.
�:
I
Bk 218+32 P:9 188 -ow-11172
I it 02-26-2007 & 09 = 14cx
1I '
i
AGREEMENT
I da of Feb 2007 b David and Jacqueline Garvin
ment is entered into this �'Y� Y q
.Agree Y
of 17335 Avenleigh Drive, Ashton, Mary9nd and the Town of Barnstable, by and through its Board of
Health,
Whereas, David and Jacqueline Garvin are the owners of certain real estate located at 992 Main Street,
Barnstable (Cotuit), Barnstable County, Commonwealth of Massachusetts, as described in a deed recorded at
the Barnstable County Registry of Deeds in Book 3153, Page 45, hereinafter referred to as the "Property", and
further described as follows:
Being LOT B containing 3,489 square feet of land, more or less, as shown on a plan entitled "Plan of Land in
Cotuit - Barnstable, Mass. for Dr. Joseph E. Lenares et ux," Scale 1 in. = 20 ft., Date: Dec. 6, 1967, drawn by
Charles N. Savery, Inc., Registered Engineers Surveyors, recorded in Barnstable County Registry of Deeds in
Plan Book 217 Page 97.
In accordance with and pursuant to'a condition of approval of variances by the Town of Barnstable Board of
Health respecting the installation of a sewage disposal system, the Property shall be subject to the restriction
that no dwelling located on the properly shall include more than three (3) bedrooms. This restriction shall run
with the land and be binding upon all successors in title. This restriction shall be released or modified only by
an instrument executed by the TOWN OF BARNSTABLE, Board of Health and by or their successors and
assigns.
The consideration for this restriction is the approval of the sewage disposal system for the Property by the
Town of Barnstable Board of Health at its meeting of November 7, 2006.
Executed as a sealed instrument this f/ day of 2007,
OWNE S GNA RE
OWNE S NATURE
as 1
Town of Barnstable
Y MA &�-S Y Board of Health
.y S. � .
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Wayne Miller,M.D..
FAX: 508-790-6304
Paul J.Canniff,D.M.D..
January 11, 2007
Mr. Glen Harrington, R.S.
9 Leda Rose Lane
Marstons Mills, MA 02648
Dear Mr. Harrington,
You are granted conditional variances, on behalf of your clients, Donald and
Jacqueline Garvin, to construct an onsite sewage disposal system at 992 Main
Street, Cotuit, MA.
The variances granted are as follows:
310 CMR 15.211: To place the soil absorption system one (1) foot away from
the right of way, in lieu of the ten (10) feet minimum setback
required.
310 CMR 15.211: To place the soil absorption system two (2) feet away from
the property line, in lieu of the ten (10) feet minimum
setback required.
310 CMR 15.211: The soil absorption system will be located 3.5 feet away from
the garage slab foundation, in lieu of the ten (10) feet
minimum setback required.
310 CMR 15.223(1): To provide a 1,000 gallon septic tank in lieu of the required
1,500 gallon septic tank.
These variances are granted with the following conditions:
(1) No more than three (3) bedrooms maximum are authorized at this
property. Dens, study rooms, offices, finished attics, sleeping lofts, and
Q:\WPFILES\HarringtonGarvin07.doc
1
l
similar-type rooms are considered "bedrooms" according to the MA
Department of Environmental Protection.
(2) The applicant shall record a properly worded deed restriction, signed by
the owner of the property, at the Barnstable County Registry of Deeds
restricting the property to three (3) bedrooms maximum. A copy of the
recorded deed restriction shall be submitted to the Health Agent prior to
obtaining a disposal works construction permit.
(3) There shall be no alterations to the foundation nor any increase in the size
of the footprint to the foundation authorized.
(4) A 45 mil rubber barrier shall be installed to provide ten (10) feet of
protection against lateral migration of effluent (between the SAS and
garage slab).
(5) The septic system plans shall be installed in substantial compliance with
the engineered plans dated October 18, 2006.
(6) The designing sanitarian shall supervise the construction of the onsite
sewage disposal system and shall certify in writing to the Board of Health
that the system was installed in substantial compliance with the plans
dated October 18, 2006.
These variances are granted because the physical constraints at the site
severely restrict the location of the soil absorption system due to the small size of
the lot (only,3,489 square feet). It is the opinion of this Board that the proposed
new septic system is designed to meet the maximum feasible compliance
standards contained within the State Environmental Code, Title V.
Sinc r ly your-I/
ayn, A. Miller, M.D.
Chair an
P
Q:\WPFILES\HarringtonGarvin07.doc
SENDER'COMPLETE THIS SECTION 1 COMPLETE THI.S SECTION ON DELIVERY
■ Complete items 1,2,and 3:Also complete A. Sign
item 4 if Restricted.Delivery is desired. X ❑Agent
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solhat we can return the card to you. B. Rec i b (Printed Name) C. Date of Delivery
■ Attach this card to the back of the mall piece,
or on the front if space permits. P , v ^�6
D. Is deli` dress different from Rem 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
lv Tvl�etie�� 7J'ia.�"/ �
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Certified Mail ❑Express Mail
CCC❑��\Registered ❑ReturnReceipt for Merchandise
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2, Article Number i! i i I I t i F e i i F S e
(Transfer from se'n%ice labeQ t� f 7 0 O 5#Q 8 2 Oi 0=0 0 4 t j7 8 5 3? 12 2 5 t;
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTAL SERVICE
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• Sender:Please print your-name,address, and Z in.this box
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SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY,
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. X(�RQ;wi
❑Agent
■ Print your name and address on the reverse ,❑Addressee
so that we can return the card to you. B. Received (Printed Name) C. Dat of D livery
• Attach this card to the back of the mailpiece, l d d 06
or.on the front if space permits.
y.' D. Is del ery ad ress different from item-1? Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
t /
1 7 3. Service Type
�`�Certified Mail ❑Express Mail
`Registered ❑Return Receipt for Merchandise
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4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(transfer from service/abed 4,:7 8 5 3.123 2,
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1640
UNITED STATECSQ =E t-4A ..55rr k8t ass
• Sender: Please print your name, address, and ZIP+4 in this box •
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DATE: O /t O`
FEE: 6JAive
+ RARNSTABLE, -A�
MASS, L.���•••r//�� REC. BY o✓
Town of Barnstable SCHED. DATE: /f Z4
Board of Health _
200 Main Street, Hyannis MA 02601
® x-
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Office: 508-862-4644 ,fit€ Susan Ci"'l�ask,
FAX: 508-790-6304 ` Sumner ufmaA- VI.S.P.H.
Wayne A.Mille .D.
VARIANCE REQUEST FORMLOCATION
-
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Property ddress: 1 2 M,4 i-/ .f7o?,c& T- P ry T— C'
Assessor's Map and Parcel Number: 0 31 /O 3 5 Size of Lot: 3, �/_ .'9
Wetlands Within 300 Ft. Yes Business Name:
No Subdivision Name:
APPLICANT'S NAME: Cir (e to C. ywrrl!id 14►., .0 f. Phone 5 0 F'4 2 t? 3 8G
Z
Did the owner of the property authorize you to represent him or her? Yes ✓ No
PROPERTY OWNER'S NAME CONTACT PERSON
Name: Dovvt d i a9�L��aG l�Tt� ✓Ue✓1 Name: 1, (e-,-, �. f✓� rr. �cra� -S•
Address: /773r �c/evt/e �,�
✓ Address:
Ail
y To Al 2 0 96 / Pa` Alfl�d�
Phone: t7 -f 7 - 5- JV T- 3 Phone:
VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space neede d)
7to C"niz /3-. /0,r Jitie- Lpt G[mJl idt� I
Sewloa�a� 9, r•?, f 5,j1
1 -10 can 2/s•�cs-- rc,�bo�4 r fv
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NATURE OF WORK House Addition 0 ????? House Renovation 0 Repair of Failed Septic System
y�
Checklist (to be completed by office staff-person receiving variance request application)
Please submit copies in 4 separate completed sets.
Four(4)copies of the completed variance request form
Four(4)copies of engineered plan submitted(e.g.septic system plans)
Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
Signed letter stating that the property owner authorized you to represent him/her for this request
Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense
(for Title V and/or local sewage regulation.variances only)
` Full menu submitted(for grease trap variance requests only)
I
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Town of Barnstable
THE rp��
o Regulatory Services
snxtvsrnBt.E Thomas F. Geiler, Director
MASS.9�A •�� Public Health Division
rF�Mpl a
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
a
April 12, 2006
Dr. &Mrs David Garvin
17335 Avenleigh Drive
Ashton, MD 02086
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5
The septic system owned by you located 992 Main Street, Cotuit, MA,was last
inspected on March 18th, 2006 by, Robert J. Bortolotti, a certified septic inspector for
the State of Massachusetts.
The inspection of your septic system showed that your system has"Failed"under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Single cesspools are an automatic failure in the town of Barnstable.
You have 2 years from the date of the system failure to bring the system into compliance.
If there are any questions about this reminder,please feel free to contact the Barnstable
Health Department.
BARNSTABLE HEALT DEPARTMENT
Th omass A. McKean, R.S., C.H.O.
Agent of the Board of Health
r _
-\ COMMONWEALTH OF'MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
~� DEPARTMENT OF ENVIRONMENTAL PROTECTION
A
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM.
PART A
CERTIFICATION
Property Address:
Owner's Name. C3
Owner's Address. o ! -1 V/ I
Date of Inspection:
Name of Inspecto pleas print)
r '
Company Namerk l /
Mailing Address: '
�' �
Telephone Numbers 7���6 `2 �
CERTIFICATION STATEMENT , 1
I certify that I have personally inspected the sewage disposal system at this address and that th6` formati6i°teported
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 system.lam a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fa11�
Inspector's Signature: �; ._., Date: -'r1�)
P
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. . /
Notes and Comments 01,v,0 e �fi'1°69,V
� //59,Y 5 �1 e.:
****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.
Title.5 Inspection Form 6/15/2000 page l
Page 2 of l l
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS'
SUBSURFACE SEWAGE"DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 99J datlLe
ak-f,4
Owner:
Date of Inspection:.
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.
I
Comments:
i
B. System Conditionally Passes:
i
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 repairs as approved by the Board of Health;will pass.
Answer yes,no or not determined(Y,N;ND)in the 1 for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years oldj* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltratiori 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:
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
distribution box is leveled.or replaced .
j
ND explain:
i
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 pipes)are replaced
obstruction is reruoved .
ND explain:
Page-3 of l 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION`FORM
PART A
CERTIFICATION(continued)
Property Address: ",-=/,, df).Q
Owner. '1- / tZ.l� Mz,,.
Date of Inspection: d .
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.
_ 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 and volatile organic compounds indicates that the well is.free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided than no other
failure criteria are triggered.A copy of the analysis must be attached to this form. .
3. Other:
3
Page 4 of.11
OFFICIAL INSPECTION°FORM . NOT FOR VOLUNTARYASSESSMENTS
SUBSURFACE SEWAGE J ISPOSAL.SYSTEM INSPECTION.FORM
PART A
CERTIFICATION(continued)
Property.Address: 919
Owner: .
Date of Inspection:
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
I/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
/ cesspool .
V Liquid depth in cesspool is less.than 6"below invert or available volume is less than %z day flow
Required pumping more than 4 times in:the last year NOT due to clogged or obstructed pipe(s).Number
J/ of times pumped .
t� 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 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.SO 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 coliform bacteria and volatile organic compounds
indicates that the well is free-from pollution from that.facility 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 forth.],
_✓(Yes/No)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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— _ the system is within 406 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 11 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.
.4
Page 5 of 1 l
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:.i I(?.) 6&ere/-
Owner:tb2- .
Date of Inspection:
Check if the following have been done.You must indicate`Yes"or"no"as to each of the followins:
Yes o
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:
Yes no
_/�� Existing information.For example, a plan at the Board of Health.
c _ 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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM INFORMATION
Property Address: ' 9-2 I`C'GC,t;G1. 1LCE °
Owner:
Date,of Inspection: QA /9-,
FLOW CONDITIONS
RESIDENTIALL1111,
Number of bedrooms.(design): Number.of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): _
Number of current residents:-1" .
Does residence have a garbage grinder(yes or no):IVO
Is laundryon a separate sewage s stem or no : if es separate inspection required]
P g Y (Y ) ,f O Y P P q ]
Laundrysystem inspecte
d no):
Y P ��
Seasonal use: (yes or no
Water meter readings, iast 2 years usage(gpd)):Sump.pump(yes or no)Last date of occupancy: je/� • -�� Cc� � �
COMMERCIAL/INDUSTRIAL A f 6
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):—
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records 7 p
Source of information:
Was system pumped as part of the inspection(yes o no): v
If yes, volume pumped: gallons--How was quantity pumped determined?.
Reason for.pumping:
TYPE OF SYSTEM
ptic.tank,distribution box,soil absorption system
_ySmg le cesspool
Overflow cesspool
_Privy -
_Shared system (yes or no)(if yes, attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank —Attach a copyof the DEP approval
_Other(describe):
Ap roximate aQ of all components,date installed(if known)and source of information:
Were sewage odors.detected when arriving at the site(yes or no): �
6
Page 7 of l I
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM
PART C
SYSTEM.INFORMATION(continued)
Property Address:
Owner: ,, -
Date of Inspection': ,� y
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(explain):
Distance-from private water supply well or suction-line: -
Comments(on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK AJ(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined;
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
GREASE TRAP:6(locate on site plan)
Depth below grade:_
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.)-
7
Page 8 of I
'OFFICIAL.INSPECTION FORM-NOT:FOR;YOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: a •���L
Owner:. . `
Date of Inspection: C0
TIGHTo I r HOLDING TANK:A/6(tank must be pumped at time of inspection)(loc,ate on,
plan)
Depth below grade:
Material of construction: concrete metal `f berglass___polyethylene other(explain):.
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present.(yes or no):.
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:, ; (if present must be opened)(locate on site.plan)
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.):
PUMP CHAMBER O (locate on site plan).
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps.and appurtenances, etc.):
3
Paize 9 of 1 I
OFFICIAL INSPECTION FORM—,NOT FOR:VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:.
s- A IuIA a
Owner: �ZC/ z , I�
Date of Inspection: / a)o(j o
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:
leachins trenches, number, length:
leachin.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.):
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:—N ' X q '
Materials of construction`.
Indication of.groundwater inflow(yes or no): .
® mments (note condition of soil, signs in�,co
of hydraulic failure,level of pond of vegetation, etc.): ,82 '` �
'PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of polling, condition of vegetation, etc.)
• 9
Pace 10 of 11
OFFICIAL INSPECTION FORM—NOT FORXOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION FORM
PART-C
SYSTEMINFORIVIATION(continued)
Property Address: k b" n��. �
Owne -y4.
Date of Inspection: t cDC)OG
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.
f
`o ot. l
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
D
Property Address: 1i.
e�. ' e> >
-14
Owner:
Date of Inspection: J
SITE EXAM
Slope
Surface water .
Check cellar
Shallow wells
Estimated depth to ground water_d feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from.system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
/�hecked with.local excavators, installers-(attach documentation)
ccessed USGS database-explain:
You must describe how you established the high ground water elevation:
lAle7*1 Ile)
. i
11 ' •
f
ins'-4•s,• .
Permit Number: Date:
Completed by
' HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: �( L- � �. � / dLot No.
Owner: Zoal f 0 Address: _
Contractor: r ddress: 1°�
Notes:
is -
STEP 1 Measure depth to water table
to nearest 1/10 f . ..........
Date r,� 116 114
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate ,
site and determine:
OAppropriate index well.................................................... *Al
Water-level range zone .....................................................
monthly
STEP 3 Using ont ly report "Current
Water Resources Conditions."
determine current depth to /
water level for index well ........................... �z w
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B) .
determine water-level adjustment .........................................................:................................ !
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
'level at site (STEP 1) .............................................................................................:...............
Figure 13.-Reproducible computation form.
15
--- ---------------------------- ------ C�
_ 9 Deslan Calculations GENERAL NOTES
a STK-'W/TAC ^'FND 90 Number of Bedrooms: 3 Existing 1. ADDRESS: 992 MAIN STREET COTUIT 0
(\I OJT 9' , Q � Garbage Grinder: NO, GRINDER NOT ALLOWED WITH THIS DESIGN 2. ASSESSORS NUMBER. 034-035
v N `` 38 4 7 ` �� 3. DEVELOPER'S LOT: LOT B
f`'�------...,.,._ �/ Septic Tank Capacity Required: 330 gpd X 200% = 660 gpd
`� 4. TOPOGRAPHIC INFORMATION WAS COMPILED FROM AN
n w Od ret' Walt et �p A\ps� Leachingtic aCapacity Required:nk Provided: 1,000 330 Gal./Dallon ay
(310 CMR 15.404 (2)(a) 5. TOWNON HW TERUISD INSTRUMENT SURVEY.
PROVIDED TO SITE & SURROUNDING PROPERTIES. M •� UC��eC
V� 6. REFERENCE PLAN: PLAN BOOK 217 PAGE 97 �"' e
Leaching Area Required: 330 Gal./(0.74 Gal./Sq.Ft.)=446 Sq.Ft. �pdg
7. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS.
i X ,58' Proposed Leaching Area Provided: 25 X 13 X 2.0 = 477 SQ.FT. 8. UNDERGROUND UTILITIES LOCATED PER DIGSAFE #20063402423
St' Total Leaching Capacity: 353 gpd > 330 gpd. req'd.
.TH #1 � � , ��` ,
0 Q SIT
»
�� C 0 T U IT '
fV d �j` y, r2
���' • �t °'� S C'Js o,� CONSTRUCTION NOTES LOCUS
NO SCALE
1. Contractor is responsible for Digsafe notification
and protection of all underground utilities and pipes.
2J4 51,83 X ,(�, 2. The septic„tank dump c"mber shall be set
level on 6 of 3N -11/2' stone.
4�' O • • OI l'IT�� 3. Backfill should��be clean sand or gravel with no
` S' O �/�1 0 l T stones over 3 in size.
6.4 `.� �� �� I I / v �C �/ I (�/� 4. This system is subject to inspection during installation
I I C by Glen E. Harrington, R.S.5. The contractor shall install this system in accordance
with Title V of the Massachusetts Environmental Code
and the Regulations of the Town of BARNSTABLE.
�� �j• 6. Provide an Acme Precast H-20, 1,000 GAL. SEPTIC TANK/500 GAL. PUMP CHAMBER,
X 5 8' an H-20, 5-hole D-box and 2-500 gallon H-20 leaching chambers or equal.
� •)� 7. No vehicle or heavy machinery shall drive over the
PROPOSED SAS �`�boa, septic system unless noted as H-20 septic components.
1 25'L X 13'W X 2.0' D �`.9 2.44 8. Install gas baffle or equal on septic tank outlet tee end.
leaching trench using 2, H-20 9. All existing inverts and site conditions shall be verified by contractor.
500-ggallon chambers `�O� �, 10. Existing CESSPOOL to be pumped and backfilled in place.
with 4' of stone all around.
LOT Bw1P 49.88' 0
AREA =3 489± SQ.FT. A, �'�, B . M # X 4921'
ho/10> cI
`�`� 1 .OS'� �eQ �0� 24" DIAMETER
'� J `` 6' i COVER TO
PERK TEST & SOIL EVALUATION �O a ``, ``:SQ � FINISHED GRADE
DATE OF PERC TEST & SOIL EVAL.: AUGUST 30, 2005 LIFT OUT CHAIN
TEST PERFORMED BY. GLEN E. HARRINGTON, R.S.
WITNESSED BY: DONALD DESMARAIS, R.S. �`. 4 ��� , �'
PERK RATE: LESS THAN 2 MPI (24 GALS. APPLIED IN 15 MIN.) Q� 45.63 `.` `` X ' ;'
Test Hole .`` ��--- _---_� �O EXISTING GRADE_ -
No. 1 tK O�
11 111 11 1 11:
DEP SOILS ELEV. PERK TEST @ T.H . #1 °'
` a y
„f PERK DEPTH=42-60"
s BEG. SOAK ® 11: 00 AM
PUMP NOTES & SPECIFICATIONS
III sod `. OUTLET INVERT ELEV.=43.89'
ze• ,orn4�e 4a. END SOAK � 11: 09 AM ' �� INLET INVERT . .
24 gals applied within 15 min. ELEV.= 44.14
USE PERK RATE < 2 MPI FOR DESIGN PURPOSES 1. PROVIDE 1 MEYERS SRM 4/10 H.P., 115 VOLT, 3/8" WEEP HOLE ABOVE CHECK VALVE
C1 SINMLPHkJEWT,.ERSIBLE PUMP CAPABLE OF PASSING (FREEZE PROTECTION)
z, A �MOt " E OF 2" DIAMETER OR EQUAL. 24 HR. Reserve Storage a 2" SWING CHECK VALVE-P.V.C.
120* ' 2. USE MEYERS CE11SW SIMPLEX ELECTRIC
No GROUNDWATER ENCOUNTERED CONTROL PANEL INDOOR MOUNTED W/VISIBLE HIGH WATER ALARM ELEV.=40.97'
SITE PLAN
48" 2$9 . PUMP ON ELEV.=40.80'
SCALE: 1 "=10' 3. PUMP SHALL BE INSTALLED IN STRICT COMPLIANCE d.
BENCH MARK ON CORNER of CONCRETE STEP WITb06 F%TIPW SPECIFICATIONS. 7.,
PUMP OFF ELEV.=40.22'
IN CONCRETE WALK, ELEv.-50.00' ASSUMED 4. ALARM SHALL CONSIST OF AUDIBLE SIGNAL & °
RED WARNING LIGHT TO BE INSTALLED IN BUILDING C
AND POWERED BY SEPARATE CIRCUIT FROM 4"
a
5. DOSE VOLUME=4 DOSES PER DAY= 330 GAL/4 DOSES=82.5 GAL./DOSE
6. ELECTRICAL PERMIT REQUIRED FOR ALARM & POWER TO PUMP. FLOOR PUMP CHAMBER ELEV.=39.89'
*NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. EXCEPT THE 2" DIAM. SCH.40 FORCE MAIN
6" of 3/4" - 11/2" Stone
*NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE.
HE Existin Grade PUMP DETAIL
Existing House Finished grade over systenI slope away asr.eox yy
twith9nro71'°of ie grtade Not to Scale
y D-Bob r must br 36"Max.
PumpChamber cover must be % hl, s `�r.an.a 9Id. Min. z 1/s-11r
to fiished rode t ra z double-washed stone
.�� aF '� ,� PROPOSED SEPTIC SYSTEM UPGRADE
••; Septic tank covers must be g s.,01
T. P -44.50' Barrier r Elev.=44.50'
6" below finished grade a 4 00, p E PREPARED FOR
redv�0 AO , 10' M M o 8 M sa" .§.tt2W Trench Elev.-Leach42.00' a A RI TO ' DAVID F. GARVIN ET UX
Existing a soh LEACH TRENCH 0.1070 AT
SLAB. efev.= 46.01 M�`� � n
Fofce , LEGEND 5.S*(5•Rim. ap'E.) Bottom of eorrler Elev.=40.50" A #992 MAIN STREET, (COTUIT)
p�oR` t's2 A/TA i BARNSTABLE, MA
`L PROPOSED 1000/500 GAL e•OF 3/e 111r STONE
H-20 S.T/P.C.
"> PROPOSED BOTTOM OF TEST HOLE #1 ELEV.=36.71 (NO GW ENCOUNTERED)
1,000/500 GAL. X 104.46 DENOTES EXISTING PREPARED BY:
SPOT GRADE VARIANCES REQUESTED - LOCAL UPGRADE APPROVAL
II SEPTIC TANK/P.C. GLEN E. HARRINGTON, R.S.
a': H-20 95-- EXISTING CONTOUR 1. A variance is requested from 310 CMR 15. 223(1) in accordance with 310 CMR 15.404(2)
to provide a 1,000 gallon septic tank in lieu of the required 1,500 gallon septic tank. g LEDA ROSE LANE
+r-�. 11 95R---"-- PROPOSED CONTOUR
2. 310 CMR 15.405 (1) (a) - A varaince is requested to allow the SAS to be installed MARSTONS MILLS, MA 02648
X > d approx. one foot from the right of way in lieu of the required ten feet.
t,a 6" OF 3/4"-11/2" STONE PUMP 20 MR DEEP TEST HOLE 3. 310 CMR 15.405 (1)(a) - A variance is requested to allow the SAS to be installed TEL: 508-428-3862
CHAMBER approx. two feet from the property line at
APPROX. LOCATION 990 Main Street in lieu of the required ten feet.
FAX: 508-428-3862
"-Id W EXISTING WATER LINE 4. 310 CMR 15.405 (1)(b) - A variance is requested to allow the SAS to be installed approx.
SYSTEM PROFILE 3.5 feet from the garage slab in lieu of the required 10 feet. „ ,
A LOCATION
5. 310 CMR 405 (1)(h) - A variance is requested to allow the SAS to be installed SCALE: 1 =10 DRAWN BY: GEH OCT.18, 2006
Not to Scale "-�-"fT"""' EXISTINXIS71N G UTILITIES approx. 5 feet from the existing water service in lieu of the required 10 feet. A 45 mil rubber
barrier shall be installed to provide 10 feet ofprotection against lateral migration of effluent. DATUM: ASSUMED FILE: GARVIN SHEET 1 OF 1
w'VLV:69:L9016[10[ - [ 1a d INi a SONIHIsaNVSiNIwnaoa-a-M-*
_-y
--------------------------- n
�� """- -- `99 Design Calculations GENERAL NOTES ,
60 V/TAC FND y~``` Number of Bedrooms: 3 Existin
`. g 1. ADDRESS: #992 MAIN STREET, CCI7UIT O
``` Garbage Grinder: NO GRINDER NOT ALLOWED WITH THIS DESIGN 2. ASSESSORS NUMBER: 034-035
t tU `38•4 7" ��^, Septic c Tank Capacity Required: 330 pd X 200% 660 d 3. DEVELOPER'S LOT: LOT B
of 'V p p y q g gp 4. TOPOGRAPHIC INFORMATION WAS COMPILED FROM AN U0
w oa re ``p Septic Tank Provided: 1,000 gallon PROPOSED (310 CMR 15.404 (2)(0) ON THE GROUND INSTRUMENT SURVEY. aC gC
t' wall r,p TiQ Leaching Capacity Required: 330 Gal./Day 5. TOWN WATER IS PROVIDED TO SITE & SURROUNDING PROPERTIES. tr
elev,�5a.16, `.��t LeachingArea Required: 330 Gal. 0.74 Gal. S Ft. -446 S Ft. 6. REFERENCE PLAN: PLAN BOOK 217 PAGE 97 odge'
q /( / q' �- q' 7. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS.
1 X ,58' , Proposed Leaching Areas Provided: 25' X 13' X 2.0' = 477 SQ.FT. B. UNDERGROUND UTILITIES LOCATED PER DIGSAFE #20063402423
A' Total Leaching Capacity: 353 gpd > 330 gpd• req'd.
.TH #1 ,b. %``, SIT
COTUIT
LOCUS
G CONSTRUCTION NOTES
NO SCALE
yT 1. Contractor is responsible for Digsafe notification
��` •� A� Q' and protection of all underground utilities and pipes.
C
214' ' 2. The septic tank ,pumpp chamber shall be set
q j, I , . • •�� 51.83 X 41 1 �", level on 6" of 3&4 um i/2' store.
Gj �y O I 1 rfr 3. Backfill should be clean sand or gravel with no
`, �•, 4` '\O' • 1 i(` O/,i�-1,ST stones over 3" in size.
6 4 ' ` ` s/_ ( ' v U ''{�, .1 1 (�/� 4. This system is subject to inspection during installation
`.� ` `,�\` �9e C� /� 1 I C by Glen E. Harrington, R.S.( I y 5. The contractor shall install this system in accordance
with Title V: of the Massachusetts Environmental Code
l.� and the Regulations of the Town of BARNSTABLE'
'O 6. Provide an Acme Precast H-20, 1,000 GAL. SEPTIC TANK/500 GAL. PUMP CHAMBER,
``. X 5 8' an H-20, 5-hole D-box and 2-500 gallon H-20 leaching chambers or equal.
7. No vehicle or heavy machinery shall drive over the
PROPOSED S 6 septic system unless noted as H-20 septic components.
AS `. 1
4' 2.44 8, Install gas baffle or equal on septic tank outlet .tee end.
1-25'L X 13'W X 2.0' D `.9�
leaching trench using 2, H-20 l . 9. All existing inverts and site conditions shall be verified by contractor.
500-ggallon chambers `,O�e p, 2� 10. Existing CESSPOOL to be pumped and backfilled in place.
with 4 of stone all around. `, ' 76 J
LOT .Or�� �`°C` 49,88` 0 CB
AREA =3,489± SQ.FT. A� ` . , B M 49,21`
/her `` •� � `` � W4 .OS, 5 �'� ,�'' 'e`
eQ �J� `0� CO ER COVER TO
FINISHED GRADE
PERK
TEST & SOIL EVALUATION CIO a ``, �`�S ��
DATE OF PERC TEST & SOIL EVAL.: AUGUST 30, 2005 �`.� ``� i�� ��
TEST PERFORMED BY: GLEN E. HARRINGTON, R.S. ��` 4 g; ' �� LIFT OUT CHAIN
WITNESSED BY: DONALD DESMARAIS, R.S. Xb 45,63' X `
PERK RATE: LESS THAN 2 MPI (24 GALS. APPLIED IN 15 MIN.) X ,3 ''
5$ .+ ��O EXISTING GRADE
Test Hole `
No. t,.
SOILS E". PERK TESTT_Q T.H #1 ' -
r
At
PERK DEPTH=42-60"
iY I
9. sw BEG. SOAK @ 11: 00 AM
11m4;6° K c� 1 : 09 AM ``., • PUMP NOTES 8c S PE C I r I C A TI GI N INLET INVERT OUTLET INVERT ELEv.=43.89'
29 4a.3 END SOAK
24 gals applied within 15 min. ELEV.= 44.14
USE PERK RATE < 2 MPI FOR DESIGN PURPOSES 1. PROVIDE 1 MEYERS SRM 4/10 H.P., 115 VOLT, 3/8" WEEP HOLE ABOVE CHECK VALVE
c1 SINMLP'-4AJEWJTERSIBLE PUMP CAPABLE OF PASSING (FREEZE PROTECTION)
"'°;� A �f OFtZE OF 2" DIAMETER OR EQUAL. 24 HR. Reserve Storage a 2" SWING CHECK VALVE-P.V.C.
UY5/4
• 2. USE MEYERS CE11 SW SIMPLEX ELECTRIC
No GROUNDWATER ENCOUNTERED ^1 CONTROL PANEL INDOOR MOUNTED W/VISIBLE HIGH WATER ALARM ELEV.=40.97'
SITE P LA V 48" 2" PUMP ON ELEV. 40.80'
SCALE: 1"=1.0' 3. PUMP SMALL BE INSTALLED IN STRICT COMPLIANCE 71F
BENCH MARK ON CORNER of coNCRETE STEP
WIT6jR�I��VAtbTl�W SPECIFICATIONS. PUMP OFF ELEV.=40.22'
IN CONCRETE WALK, ELEV.-50.00' ASSUMED • 4. ALARM SMALL CONSIST OF AUDIBLE SIGNAL &
RED WARNING LIGHT TO BE INSTALLED IN BUILDING 4
AND POWERED BY SEPARATE CIRCUIT FROM � 4"
5. DOSE VOLUME=4 DOSES PER DAY= 330 GAL/4 DOSES=82.5 GAL./DOSE
6. ELECTRICAL PERMIT REQUIRED FOR ALARM & POWER TO PUMP. FLOOR PUMP CHAMBER ELEV.=39.89'
*NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. EXCEPT THE 2" DIAM. SCH.40 FORCE MAIN 6" of 3/4" - 11/2" StonMe [@
*NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE.
HE Existil, Grade PUMP DETAIL.
ExistingHouse asr.eox,
Finished grade over system=2% slope away
Not to Scale
Min.2•-1/$'-1/r 12'm
Box lava must ba 38'max•
ri in & of finished grode _ \�N OF
Pump Chamber cover must be dahie-Roehed.tons PROPOSED SEPTIC SYSTEM UPGRADE
Septic tank covers must be to finished grade tewitax �� „ =44.50' i Elev.=44.50' �.Q
6" below finished grade Z, to' = a.00' o E PREPARED FOR
Ap b ---- a o o e,, 24•�t3ott m of ebe HA iV TQ + DAVID F. GARVIN ET UX
edv\e , 4 2s• Trench Elm- 42.00' 0.1070 � AT
SLAB. .lave= 4s.ot' Existing/race Mottsor LEACH TRENCH 9 0
n Bottom of Barrier Elev.-40so" F k. #992 MAIN STREET, COTUIT
Force' LEGEND 6.3't(s min.read.) s1rS
sq^!/TAR`P BARNSTABLE, MA
to 2 a 016 HR S,T/P 10 0/300 GAL 6'of 3/4'-11/Y SME
'> PROPOSED BOTTOM OF TEST HOLE #1 ELEV.=36.71 (NO GW ENCOUNTERED)
1,000/500 GAL. X 104.4s °s or°caaoEl�NG `VARIANCES REQUESTED - LOCAL UPGRADE APPROVAL PREPARED BY:
11 SEPTIC TANK/P.C. GLEN E. HARRINGTON, R.S.
> H-20 t''a 95 EXISTING CONTOUR � 1. A variance is requested from 310 CMR 15. 223(1) in accordance with 310 CMR 15.404(2)
c
d to provide a 1,000 gallon septic tank in lieu of the required 1,500 gallon septic tank. 9 LEDA ROSE LANE
{., 11 95P-- PROPOSED CONTOUR /z. 310 CMR 15.405 (1) (a) - A voraince is requested to allow the SAS to be installed MARSTONS MILLS, MA 02648
approx. one foot from the right of way in lieu of the required ten feet.
w 6" OF 3/4"-11/2"STONE PUMP d DEEP TEST HOLE V/3, 310 CMR 15.405 (1)(a) - A variance is re nested to allow the SAS to be installed
CHAMBER > approx. two feet from the property line at �#990 Main Street in lieu of the required ten feet. FAX: 508-428-3862
APPROX. LOCATION FAX: 508-428-3862
EXISTING WATER LINE 4. 310 CMR 15.405 (1)(b) - A variance is requested to allow the SAS to be installed approx.
SYSTEM PROFILE 3.5 feet from the garage slob in lieu of the required 10 feet.
5. 310 CMR 405 (1)(h) - A variance is requested to allow the SAS to be'Installed
SCALE: 1„=10, DRAWN BY: GEH OCT.18, 20t�6
Not to Scale APPROX. LOCATION approx. 5 feet from the existing water service in lieu of the required 10 feet. A 45 mil rubber
EXISTING UTILITIES barrier shall be installed to provide 10 feet ofprotection against lateral migration of effluent. DATUM: ASSUMED FILE: GARVIN SHEET 1. OF 1
17 73S" /7VCO V11V _V:89:L9016V0L - L ]SVd INIWIg' SJNI.LL3SGNVS1N]iNnooc o-M-M