HomeMy WebLinkAbout1160 MAIN STREET (COTUIT) - Health 11 W Main Street, C®tuit
Commonwealth of Massachusetts _�1 _ ,
Title 5 Official, 0 nspectuor Foem'
' r�t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;
1160 Main St
Property Address
Anthony Salerno t r
Owner Owner's Na e , r_
information is Cot f� r „•' MA 02635 3-4-21 •; `
required for every
page. City/Town ,, State Zip Code Date of Inspection,,
f n
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.
A. Inspector Information S14r IS 11&S .
Shawn Mcelroy
Narne of Inspector j .. + :,�. , „•,,., .. .
Upper Cape Septic°Services
Company Name `
P.O. Box 73
Company Address
East Falmouth 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:) 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'theproperty 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 + , _ .<• ., 1 .. ,; „
-, tr 2. ❑ Conditionally Passes„ -►,_
x , 3. ❑• Needs Further,Evaluation,by the,Local Approving Authority. , - • „ ,
4. ❑ Fails
' a� r�' .. r•I t ir.rt a' , ,, ,,:t.
-4-21
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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 .
cam" Commonwealth of Massachusetts r
Title 5 0 coal Inspection Foy 6i '
it Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments -: r
tier' 1160 Main St r - '
Property Address t
Anthony Salerno `
Owner Owner's Name
information is required for every Cotuit t' MA 02635 3-4-21 j
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: - •- '' `
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any.failure criteria not evaluated are
indicated below. y
Comments:
System is in good working order with no sign of failure. T
"2) System Conditionally Passes: '-
One or more system components as described in the"ConditionalPass"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 t ❑ ND (Explain below):
t
is
t
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official lnspect10fi,,,F6'rm` . ,-,,,,
r-411 Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments
1160 Main St
Property Address
Anthony Salerno
Owner Owner's Name
information is
required for every Cotuit MA 02635 3-4-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are'repaired El 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
pas`s. insoe'c't*i'on'if'(�4ith"a'p'pr'ova'I of B6*ard of Health)-'
Q
E bro en pipe(s) are repla66d E , y34 -El"ND (Explain below):
El obkru&i6n-is�er�o'vheb 0 y —a ND (Explain below):
El diitribbtion box is'leVeled br,replaced' Ely " D N'- El"ND,(Explain below):
4" 1) or. 7,
F 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):
El broken pipe(s) are replaced Ely [IN El ND (Explain below):
❑ obstruction is removed F-1 Y EIN El ND (Explain below):
3) Further Evaluation is Required,by,the Board of Health:
El Conditions exist which require further evaluation by.the Board of Health in order to determine if
16 system` is failing to or6t'e6t'oublic'*h6'a'lth,,-sa-f'e't'yF or-'the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(4)that the system is not functioning in a.mannerw hich will protect public health,
safety and the environment:
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18-
Commonwealth of Massachusetts
Tile 5 Official Inspection l=o IM
%1 Subsurface Sewage Disposal System Form =Not for Voluntary Assessments �" w
1160 Main St '
J"
Property Address
Anthony Salerno r
Owner Owner's Name
information is Cotuit MA 02635 3-4-21 '
required for every '
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 soiliabsorption 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 SA_ S is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 1 00 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: ,..�. • ; s , ,
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts r E. ��. ... :� , •f x. �`
,J) t Title 5 O�'�'iciai. Inspecti®n-F 'rm. - 1 F
! 0 Subsurface Sewage Disposal,System Form -Not for•Voluntary Assessments , I, , :c
' 1160 Main St rr� t;, r•
Property Address
Anthony Salerno �:.a '_.4 ; ,-•'�
Owner Owner's Name
information is ,
Cotuit c ��• a ,. MA 02635 3-4-21 `
required for every '- -
page. City/Town State Zip Code Date of Inspection ,
C. Inspection Summary (cont.) > .t ,�
,e 4)r System Failure Criteria Applicable,to All Systems: (cont:) �� Ft • . ,
Yes; ,No tl ...-If ti p`t. la ,. ,!w,t J;t( " '1't,' `i •, :�^- , .. ♦s. V)t
❑ ® Static liquid level in the distribution-box above outlef 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
,` ❑ ® t ' :than Y2 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 groundwater elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
u ❑' `� ® tributary to(a surface water supply. '
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
t �❑ t ® 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 wifh no acceptable water quality analysis. [This
4 ?_ t- > >• . -system passes if the well,.water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
tof 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.],
EJ
The system is a cesspool serving a facility with a design flow of 2000 gpd-
fi0,000 god
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
etx ,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. '
r .-i - •° For large systems, you must indicate either"yes".oc'`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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts + - ; �• r
201
Title 5 Official , In- Forte
,i i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V7r .,r' 1160 Main St
Property Address
Anthony Salemo ;
Owner Owner's Name
information is
required for every Cotuit •c MA 02635 3-4-21
page. City/Town 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 a ro o riate' e r ional office of the Department.
PP P , 9 , - .
6: You must indicate "yes" or"no"for each of the following for afl 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 normalrflows'in the previous two week period?
e .
El . ® r 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?
®' t a❑• Was the site inspected for signs of break out?
® ° `" ❑ r = -Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank man holes'uncovered, opened, and'the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
j r dimensions,'depth'of liquid,`depth of sludge and depth of scum?
® ❑ Wasthe 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`plar 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)1[310 CMR 15.302(5)]
e~ ;
f.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts ;: r .• :.� ; ' _ r �:. , ' ,
f . Title 5 Official Inspectionfor
hi Subsurface Sewage Disposal System-Form :Not for�VoluntaryiAssessments t.: .cd:.
;7
1160 Main St
Property Address .
Anthony Salerno
Owner Owner's Name
information is Cotuit MA 02635 3-4-21
required for every -
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: +., ot•. ; , s_ ,,, 7 s,t _
Number of bedrooms (design): N/A Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for-example: 110 gpd x#of bedrooms): N/A
c, .
Description:
♦. N 'its . •
_ + Number of current residents: P, ,£1 r„ 1
Does residence have a garbage grinder? ., �� ,• ,,t , ..,t. t' y El Yes ® No
Does residence have a water treatment unit? F,tl,;..•r_[ �,, k, ,_F - i a ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (include laundry system inspection'` ❑ Yes ® No
information in this report.) '
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
h.
Sump pump? +,: t �: ❑ Yes ® No
-Last date of occupancy: rt , 4 " 3-2021
Date
t5insp.doc-rev.7/26/2018- _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
cam° Commonwealth of Massachusetts .•i
Title 5 Official Inspecta®n form
! i�l Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
1160 Main St
Property Address
Anthony Salerno
Owner Owner's Name
information is required for every Cotuit MA 02635 3-4-21
?"
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) : .
2. Commercial/Industrial Flow Conditions: t :" ' ••
Type of Establishment: '
Design flow(based on 310 CMR 15.203): '
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5"system? f r: ❑ Yes ❑ No
Water meter readings, if available: i
Last date of occupancy/use: ?
Date
Other(describe below): r" 4
r,
3. Pumping Records:
Source of information: Owner----pumped 2007
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I
Commonwealth of Massachusetts �< -; i:��,. .,•, n _ : c 41
f Tide O ici�l L spec i®a� forni
N Subsurface Sewage Disposal System Form.Not for Voluntary Assessments.; J1
1160 Main St ,
Property Address 2 ,.
Anthony Salerno
Owner Owner's Name
information is
required for every Cotuit '.`., h MA 02635 3-4-21
page. CityfTown ;s State Zip Code Date of Inspection
D. System Information (cont.) r r► . , : -, ;�,; _;
4. Type of System:
® 'rSeptic tank, distribution box, soil absorption system ,I
❑ Single cesspool -r.,. ,.. 1 „
❑ .,„ i t. Overflow cesspool,, - ;
LI. r- Ala
❑ 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,.• t,,,;�
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1970's with leach pit added in 1997
Were sewage odors detected,when arriving at the.site?t ,;,4 ,•sx ,a❑ Yes ® No
5. Building Sewer(locate on site plan):-,
24"
Depth below grade: ``= ` }• � feet
r ' Material`of construction:` i'' r, ` 'n . ' :« J'-4
Elcast iron 040 PVC ` ❑ other(explain): '
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 -
Commonwealth of Massachusetts -
,'� Title 5 Officisl Ifispec$ion. For' hf ,
I Subsurface Sewage Disposal System Form Not for Voluntary Assessments=• y
1160 Main St
Property Address •+
Anthony Salerno T
Owner Owner's Name
information is ,
required for every Cotuit c • ,r �` MA 02635 3-4-21 '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan): " • ,= ;
Depth below grade:
18"
feet
Material of construction: r ,,
® concrete ❑ metal ❑ fiberglass +❑ polyethylene ❑ other(explain)
If tank is metal,•list age: { ` ' _ ' -
years
Is age confirmed by'a Certificate of Compliance? (attach'a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
1
Sludge depth:
12"
Distance from top of sludge to'bottom of outlet tee or baffle r -2011,
Scum thickness
Distance from top of scum to top of outlet tee or baffle 6"..
Distance from bottom of scum to bottom of outlet tee or baffle °
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage—
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts t A' r r t t
,, Title 5 Official Inspection horn .
gal "'
� i Subsurface Sewage Disposal System Form Not for-Voluntary Assessments t u•t
r ;
1160 Main St
Property Address
Anthony Salerno t
Owner Owner's Name
information is ,
required for every Cotuit _, ; f r. MA 02635 3-4-21
page. City/Town - t State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan): , �.,,; ,,�• , ,4
Depth below grade: feet'
Material of construction:,
❑ concrete ❑ metal ❑ fiberglass ❑,polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:,-,,. < " �r t , •,_, ! -K . r,
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):
,,, R .•^-. ") +—.iR 04". IS'.._. e, .t ,t , c >J --+ 'r, I'. 't /•+ ',r , .,i .Y• }
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018., Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18.
4ev,, Commonwealth of Massachusetts
Title 5 Official- I nspec$ioh - For m_- >
3 .•
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1160 Main St
Property Address ,
Anthony Salerno -
Owner Owner's Name
information is Cotuit '� �+ MA 02635 3-4-21
required for every - '
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:, ❑ Yes El No' "
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: 1 Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? '❑ Yes ❑ No
9. Distribution Box (if,present must be opened)(locate on site,plan): �+
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from pits.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts -c., t,�•• +
Title 5 Officia.8, i nspectioh. Foft
Subsurface Sewage Disposal System Form Not.for,Voluntary Assessments
1160 Main St r �;
Property Address f,•
Anthony Salerno
Owner Owner's Name
information is MA 02635 3-4-21
required for every Cotuit r ,
page. City/Town •. State Zip Code Date of Inspection
D. System Information (cont.) ��• �� �� j; ; ,- . , .i}
10. Pump Chamber(locate on site plan):
" - Pumps in working'or`der:` ,,, „ _ . t-'� .. ".'' ' A. �❑ ._Yes ❑ No*
Alarriis in working order: '' -`' E, a "' `' ❑`Yes` ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation,not required):a
If SAS not located, explain why: r•s, ;, r,. ,,, �'t
a { rj7
r � r
Type: F . r- j • y t
leaching pits j `''' ' " ' ` ' -number' 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 1-6x6
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18-
Commonwealth of Massachusetts
Title 5 Official Inspection i=oriii - �
i i-i Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments '
1160 Main St
Property Address
Anthony Salerno
Owner Owner's Name
information is required for every Cotuit MA 02635 3-4-21
page. City/Town - State Zip Code Date of Inspection
D. System Information (cont.) � l ' l ►
11. Soil Absorption System (SAS) (cont.) tt '•, '
Comments (note condition of soil, signs of hydraulic failure„level of ponding,,damp soil, condition of
vegetation, etc.):
Overflow cesspool was in good condition and holding 12"of water at inspection. Leach pit was empty
at inspection with no visible stain lines. i • +
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration • - - F, .•
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.):
f
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts -
� ; Title 5 Official l nspectaon�,•Fotm• .5 -•'' ,i
Subsurface Sewage Disposal System Form;Not for Voluntary Assessments to ;,I';
1160 Main St
Property Address - ,,,,,•
Anthony Salerno
Owner Owner's Name
information is
required for every Cotuit MA 02635 3-4-21 1• ,f,
Cit /Town State i
Y k, Z Code Date of Inspection
page. p P
D. System Information (cont.) rtF-: �, , , , , <<� ,ry. •�
13. Privy (locate on site plan):
Materials of construction } �`� '` , n` t g '' ►� "'
Pt:, a..�,r f �,. # �) ICI k _�l,.r ; ,.N1 - �. }
Dimensions
,y,1�F•`, � Ems. ', , ,i,• ,'. ,
Depth of solids ►'I ` I
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):_
IL
"f
t y
{
t I III
}
• x+.w
• 1}
y M1 • y •
,
t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
w.
dal Subsurface Sewage Disposal System Form Not for.Voluntary Assessments r
s T " 1160 Main St
Property Address
Anthony Salerno
Owner Owner's Name
information is Cotuit _ MA 02635 3-4-21
required for every
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
❑ drawing attached separately
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official InspeCt10Q� FOPm'
i Subsurface Sewage Disposal System Form Not for�Voluntary Assessments,: -;A
r KI
1160 Main St
Property Address
Anthony Salerno t I
Owner Owner's Name
information is
required for every Cotuit MA 02635 3-4-21
page. City/Town State Zip Code Date of Inspection
d
D. System Information (cont.) , .-,.
15. Site Exam: , �r n;* {t r� - ..,y �. ;t s hqy ., '►
❑ Check Slope ,. ,. +, , • .- •+3,a, u;< , +' . ;t. , - / ;
❑ Surface water
❑ Check cellar ;
❑ Shallow wells
Estimated 9
depth to high round water:, ;`I,• �, , 20+ ,
p 9
• 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 plamreviewed: "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:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
c Commonwealth of Massachusetts . •_' "
Fill 04 Title 5 Official Inspection' ,. Foy
} Y%r Subsurface Sewage Disposal System Form Not for Voluntary Assessments M
1160 Main St
Property Address
Anthony Salerno
Owner Owner's Name
information is Cotuit MA 02635 3-4-21 `
required for every -
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed 8r Dated and 1, 2, 3, or checked
® C. Inspection Summary: '
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed • r ' — '
® D.-System Information: • • /
For 8: Tight/Holding'Tank—, Pumping contract attached
For 14: Sketch of Sewage Disposal,System drawn on pg. 16 or attached
For.15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
V
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI
10
kil J;W;�, DEPARTMENT OF ENVIRONMENTAL PRO OI d�
ONE WINTER STREET. BOSTON, MA 02108 617-292.5 6b
n R50
10,9
WILLIANI F.WELD \`\� e�NSSjg�E T kUQ cc OXE
Govcmor J V
ARGEO PAUL CELLUCCI 100WN��e DA STRUHS
Lt.Govcrnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR mmissioncl
PART A .4 eb
CERTIFICATION
Property Address: 1160 Main Street Cotuit,Mass Address of Owner:Joanne M. Roy
Date of Inspection:6/20/97 (If different) 101 Springhill Road
Name of Inspector:Joseph P.Macomber Jr. North Andover Mass . 01845
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J. P.Macomber & Son Inc.
Mailing Address: BOX 66 Centervi 11 P ,Ma G q, f12632
Telephone Number: 5ng-77 3 3 3 ".,r,_TAR
CERTIFICATION STATEMENT
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-yewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: /"/4�6k�' Date: �7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
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.
Indicate yes no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http://www.magnet.state.ma.us/dep
> Printed on Recycied Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
h PART A
CERTIFICATION (continued)
Property Address: 1160 Main Street Cotuit ,Mass .
Owner: Joanne M. Roy
Date of Inspection: 6/20/97
B) SYSTEM CONDITIONALLY PASSES (continued)
A16 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
.V The system required pumping more than four 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
Cj 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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
(�d 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
&16 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
&0 The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the pr'es�ence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance �' (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
II �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1160 MAIN Street Cotuit,Mass
Owner: Joanne M. Roy
Date of Inspection:6/20/97
D) SYSTEM FAILS:
You must indicate ewer "Yes" or "No" as to each of the following:
- 'L� I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an 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 ¢jstribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in'cesspo fait
pool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
. The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
d/1¢ 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
&,4 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Joanne M Roy
Owner: 1160 Main Street Cotuit,Mass .
Date of Inspection: 6/20/97
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, clluding the Soil Absorption System, have been located on the site.
— The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddre55: 1160 Main Street Cotuit ,Mass .
Owner: Joanne M. Roy
Date of Inspection.6/20/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow:'?V-g.p bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):�_
Laundry connected to system yes or no):*
Seasonal use (yes or no):P
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment: AM-
Design flow: VA allons/day
Grease trap present: (yes or no)44
Industrial Waste Holding Tank present: (yes or no)_W'
Non-sanitary waste discharged to the Title 5 system: (yes or no)-49
Water meter readings, if available: A1,4
Last date of occupancy: N
OTHER: (Describe)
Last date of occupancy:=
GENERAL INFORMATION
PUMPING RECORD and sou ce of information:
d
System pumped as part of insp,��}cti—on: (yes or no)
If yes, volume pumped: . . gallons
Reason for pumping:
TYPE OfSYSTEM
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)
tR VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGf of all comp nts, date installed (if known) and source of information:
�~.�211/ � (� 7/ � �e Sys ,,� i 9-n 111:3
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 160 Main Street Cotuit,Mass .
Owner: Joanne M. Roy
Date of Inspection:6/20/97
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron Z40 PVC—other (explain)
Distance from private water supply well or suction line
Diameter 4W—
Comments:.(Sondition of joints, venting, evidence of leakage, etc.)
.1� �',¢cv �i 9.�t�>oi SV J'�1�� i S /-�.v
SEPTIC TANK:Zev9if/4�t7
(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 Certificate of Compliances (Yes/No)
Dimensions:
Sludge depth:, 1:-�__ /����
Distance from top of ludge to bottom of outlet tee or baffle:;��ee—
Scum thickness:
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom (outlet tee or baff le:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
inte ri , evident of leakage,etc.) pp!jmD se tiC tank e rs very 2-3 _ yea : Inlet Rr out7 et. tPPs
are in place ; Liquid leyei ab Outletiert, 15 5
structural ,yam sound;No evidence of leakage , Septic dank is
GREASE TRAP:,&���
(locate on site plan)
Depth below grade:1i�
Material of construction40,concrete IflAmeta10Fiberglass.iWPoI yet hylene.fAther(explain)
Dimensions: Vlq
Scum thickness:�i O
Distance from top of scum to top of outlet tee or baffle: dVJ9
Distance from bottom of scum to bottom of outlet tee or baffle:—L/'�
Date of last pumping: A)fi
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
Grease tra12 is not present
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1160 Main Street Cotuit,Mass .
Owner: Joanne M. Roy
Date of Inspection: 6/20/97
TIGHT OR HOLDING TANK:4A . ank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:,6
Material of construction.1�lconcrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: 41,4 gallons
Design flow:. gallons/day
Alarm level: Alarm in yvorking order _ Yes; —
No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Distribution box is ievei and Has two a era s : o evii1ence ol soiqs
carry over :No evidence of ieakage in or out of the- distribution box.
PUMP CHAMBER: ,Ay�
(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.)
Pump Chamber is not present
(revised 04/25/97) page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1160 Main Street Cotuit ,Mass .
Owner: Joanne M. Roy
Date of Inspection:6/20/97
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dime ions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Cotuit sand:No signs of hydraulic failure or ond' n 1� y p i g.A 1
vegetation is normal
CESSPOOLS: ,.JZ/
(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: lVeWe
inflow (cesspool must be pumped as part of inspection) {/A.
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
o ui san :no signs ol Hydrauilc failure or pon ing: Allvpgetation is
norma .
PRIVY: •dye-
(locate on site plan)
Materials of construct[ n: i+/•� Dimensions: L�
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
rivy is not present.
(revised 04/25/97) Page 8 of 10
G
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1160 Main Street Cotuit,Mass .
Owner: Joanne M. Roy
Date of Inspection: 6/20/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
\ � 0 �
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0
0
GX6
i
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGj DISP0,AL SYSTEM INSPECTION FORM
P..;t7 C
SYSTEM INFOR>,'.-.TION (continued)
Property Address: 1160 Main Street Cotuit,Mass .
Owner: Joanne M. Roy
Date of Inspection: 6/20/97
Depth to GroundwaterlJ Feet
Please indicate all the methods used to determine High Groundwatc( _vation:
Obtained from Design Plans on record
observation of Site (Abutting property, observation hole, basci : ni sump etc.)
_ZDetermine it from local conditions
heck with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Ground.....t:r Elevation. Must be completed)
J. P.Macomber & Son Inc . Added 1 -1000 gallon precast
leaching pit to the existing system in December Of 1983 .
No water encountered at 12 '
(revised 04/25/97) Pages : : of 10
r
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I TOWN OF Barnstable BOARD OF HEALTH
1 SUBSURFACF 9FWAGF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
`- A"'�'^.-r ...--.11 ^.-.1tr.�`n•R.rnrllr FTrr t-.Tr1-�—•.•irlmr.�arnm^T�tf*+C'v1.T�+rTcr� . nnrinllmrr.rtiv-T1-P+rr+r.:—.rrrr-�. —.
-TYPE OR PRINT UEARLY-
PROPERTY INSPECTED
STREET ADDRESS 1160 Main Street Cotuit ,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Joanne M. Roy
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J. P.Macomber & So-f 'INC .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State ZIP
COMPANY TELEPHONE ( 508 I 775 - 3338 FAX ( 508 ) 790- 1578
.'t
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of .-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
XXXXXXXXXXSystem PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or- Lhe environment as defined in 310 CMR 15 . 303 . Any failLIre
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have conducted has found that the system fails to
Protect the Public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date 6/20/97
One copy of this c rt.ification must be provided to the OWNER, the BUYER
( Where applicable ) and the BOARD OF IIEALTII.
* If the inspection FAILED , the owner or " 'Pa rator shall u
within one year of the date of the inspection , unless allowed dortrequiredm
otherwise as provided in 3.10 CMR 16 . 305 ,
partd . doc
—•i
UU) 7C7
Jb �C
Sb'lV 7:Y
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
Juno 8. 1995
Acting Dircctor of the - ion of Watcr Pollution Control
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TOWN OF BARNSTABLE
LOCATION SEWAGE #
VELLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILrTY: (type) �� '� _ (size)
NO.OF BEDROOMS
BUILDER OROWNERNZ64,0,R !
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Welland andl eaching Facility(If any we lands exist,
within 300 feet f 1 hing ility,) � n� Feet
Furnished by � OK/ q
r
� � 3
G
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA LER'S NAME & ADDRESS
�r4W Go^6 6Re �4-Al)�g 61 a./7�a ZZ
® UILDER- 0 OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
T. .
__ _ _ ._ _ _
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�c� ��'� .��'� `�
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No..f�...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......1.(� W.rY).. ........OF.... vs :.e..........................
Appliration for Biovoiia . luorkii Tonotrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (L)-an Individual Sewage Disposal
System at:
ocation- dre s or Lot No. ��-����� -
J9 ...� ...... a .........•....
_ •••• -----------------------
Owne .........._
IR-41 .6,0i -
dress
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g ---------------•----------•• P ( ) — Cafeteria ( )
Otherfixtures -----------------------------------•-------.......---.---•-•-•••-•-••••••---••--•-•--•-..........•-••---•----......•------•••••....--•---••-•••..----•
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------------- Diameter.................... Depth below, inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................•--------......._............_•..... Date........................................
W
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fY4 Test Pit No. 2................minutes per inch Depth of Test Pit...............:.....Depth to ground water........................
-------------
,.� .........
. ................
O Description of Soil.............• sr lX.. .�Y /--•--••---------------------------------.---------------------- -•--.--.-.------
x .
U --------------------------------------•---•---------•------------•--------------•-- ----------------------------------•----•--•----•-------•------------------------------•----•-------------------
W
U Nature of Repairs or Alterations—Answer when applicable....__. .:� .. �'1..... ...........................
�...:1- Q... .... ----•---------------------------------•------•---•-••-•-•.---
Agreement:
The undersigned agrees` to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of I'11E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beg begn issued by the oa of health.
Date
Application Approved By......... ......• ......
........................- ..............
Date
Application Disapproved he ing reasons:................................................................................................................
.. .. .•-••--•-•••-•••.....••......-•...................................•--•--..._-•------•-•---•-•-•----••--•-•. •-------•••- -•--••......-
Date
PermitNo......................................................... Issued.......................................................
Date
i
t THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
Appliration far Uiiipuittl Works Tontrnrtiun amit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
'. ......................•-
,' vf"bpcationdress or Lot No.
-....
Owne dress
W
Installer Address
_ Type.of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .------•---•••••-•-••••-••••••-••-•-•--•••-•-•---•••••..........................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---............. Depth................
xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No............:........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
IX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
aO ------•--------.-- .....
Description of Soil................. .. .. ' :
x If/•---...•---------•--•-------•-•..............................:
V ......................................•-•-•••---.._............----------............------•--•--._......._....---•••------•-•-•----------------•---•--••----.......--•-•--------••---•----------.------
W
UNature of Repairs or Alterations—Answer when applicable ....... .............•.
_t Z.•-----....-•-- -------------------- -------- ---------
Agreement: .41
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by thehoa>V�� health.
f t � c
S' ne .a .,..R's¢x�s..3: _.-�''� �''1�+�^ �'' ��' cA {' -----
. a------• t--!` ---- •=9 --- -Date
ApplicationApproved By----•-.._::r:- •-----•••••••.............•-------••-•-•--....-----•--........_......---
Date
Application Disapproved for e fa owing reasons:..............................................................................................................
.
..................................................................................................................................•------------------------------------•------------.....---•--•--------
ISate
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........).014,0,a4..........OF......: r. ........................
�rrtif irtt#r of f�unt�Ii�tnr�e ,
THIS 0 CERTIFY, That the Ind v'du Sewag is osal System constructed ( ) or Repaired (Z_�
by--•- ...Q.1.�.. �.�1f��1 �...� ? �........................................................ ---.--------.---
/// /y f Instal at...... /1i10..... `
..
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSIIA C - OF THIS CERTIFICATE SHALL NOT BE—CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WIL F CTION SATISFACTORY.
DATE....f ... ... .................................................... Inspector........... •---......----•----•--.........-----......------....----•-••---......
f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF� HEALTH
! ✓ ..OF...... =t ................................
No.... �"�1
�i,��r�a,�tt1 nrk� �vrn ��l.rtUa rrnttt
Permission is hereby granted.... .........
to Construct ( ) or Re air (,)_,.an Ind vidual Sewage Disposal System
t J -
at No...................... . 'f` : �1��� ....._.
�_
Street
as shown on the appli tion for Disposal Works Constructio/Permnit . .............. Dated_._....___._.__._..._......_......._..._..
....._ ----- ........................................................
/,• Board of Health
DATE----l '` �i _... ....:_.:
FORA4 1255 A. M. SULKIN, INC., BOSTON