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Home My WebLink About1326 MAIN STREET (COTUIT) - Health 1326 Ma n SFp- L G i i �I a� t Commonwealth of Massachusetts 0 0d 3 ,? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1326 Main Street { u E .. Property Address -y James McDonough Owner Owner's Na e information is required for every Cotuit MA 02635 03/12/2020 page. City/Town State Zip Code Date of Inspection `Inspection results must be submitted on this form. Inspection forms may not be,altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information S/0 filling out forms /qGJ,S—c) 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 „Q Company Address Teaticket Ma. 02536 I� City/Town State Zip Code 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 03/13/2020 In pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 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 5 bedroom home has a main cesspool feeding a precast leaching pit with stone. At the time of the inspection both were dry and no visible failure criteria was found. 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 118 I Commonwealth of Massachusetts Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 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 ❑ ® 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. Citylrown 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 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 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 CM 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form 5i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out In the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. !% 1326 Main Street u� Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 55 plus GP Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage Town water 9 ( Y 9 (gPd))� Detail: In 2019-256,000 gallons were used and in 2018-396,000 gallons were used Sump pump? ❑ Yes Z No Last date of occupancy: Fall 2019Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �n p Title 5 Official Inspection Form �< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ........... 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons t How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/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): Main cesspool feeding precast leaching pit with stone Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. City/Town 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 ❑ 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: 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form `l, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: . ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 IL Commonwealth of Massachusetts �n = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) a Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑. No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owners Name information is required for every Cotuit MA 02635 03/12/2020 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ' If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I Commonwealth of Massachusetts ,p Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the leaching was dry and no visible failure criteria was found 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Round Depth—top of liquid to inlet invert Dry Depth of solids layer Dry Depth of scum layer Dry Dimensions of cesspool Appx 6 x 6 Materials of construction Red brick Indication of groundwater inflow ❑ Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): At the time of inspection the cesspool was dry. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 \ Commonwealth a Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is COtUIt required for every MA 02635 03/12/2020 page. C41rown 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 A B 1 32' 34' A B 2 48' S0' r) 0 O O Oceanview Ave t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 f _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 117" plus 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: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation 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 Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1326 Main Street Property Address James McDonough Owner Owner's Name information is required for every Cotuit MA 02635 03/12/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ' FOR MAIL-IN.REQUESTS FOR ALL CORRESPONDENCES: Please be sure to include the address, unit number and village you are referencing to.- Email Address: Bamstable.Rental.Registration@town.bamstable.ina.us A separate application form should be submitted for each rental unit you have. Mail the completed application form(s), along with the required fee amount(see fees at bottom of this page), to the address below.-Che&should,be made payable io:_Town:of Barnstable. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis;MA 0260f "t 1 , >.- ti To get a rental,registration application form, click here. To be able to access this form, your computer must have Acrobat Reader."Most computers have Acrobai Reader, and it will usually activate itself automatically. If your computer does not have Acrobat Reader,you can download a copy of it by going to the Adobe website. FEES Fee: $90.00 Per Unit plus$25 for each additional rental unit on the same property, with the same owner. For further assistance on any item above, call (508) 862-4072 or 5087862-4644: Thank you. Q:\PROJECTS\Health\RentalRenewalMailing\2013\Application for Rental Reg.Renewal 2013.doc PAGE 2 OF 2 . INSTRUCTIONS ON PAGE 2 cNtcnl onou I � )� M7LtC 1,S, aOC6 P COS tiJCUJJ I€f� me Iw slat Arbil c8� IS 6 c� pruc cT cp-� Lr- raol I t:DppmsctcL6 cu( ►rx �1 I y I 1 Septic System Inspection Report 1326 Main Street ' Cotuit, Massachusetts RECEIVED ' AUG 13 2001 TOWN OF BARNSTABLE HEALTH DEFT. July" 10, 2001 Prepared For: ' Richard and Ngaire Cuneo 674 Weed Street F New Canaan, Connecticut 06840 Prepared by: William E. Robinson, Jr. Septic Inspections 43 Tomahawk Drive ' Centerville, Massachusetts 02632 1 I y_ 1 1 y A� 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION e 5' TITLE 5 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ' PART A CERTIFICATION ' Property Address: 1326 Main Street,Cotuit Owner's Name:Richard&Ngaire Cuneo Owner's Address: 674 Weed Street New Canaan,CT. 06840 Date of Inspection: July 7,2001 Name of Inspector:(please print) William E.Robinson,Jr. ' Company Name: William E.Robinson,Jr.Septic Inspections Mailing Address: 43 Tomahawk Drive Centerville,MA. 2632 Telephone Number: (508)775-7986 ' 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 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: ' X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's s Signature: L Da te: July 10,2001 The system inspector shall submit a copy of this insp on 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 ' Although not a Title V design, the septic system appeared to be in good functioning condition on the day of inspection. Please note that this system receives minimal yearly use. ****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. ' Page 2 of 11 ' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION (continued) Property Address: 1326 Main Street,Cotuit Owner:Richard&Ngaire Cuneo Date of Inspection: July 7,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D ' A. System Passes: ' X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic system was found to be in good working condition on the day of inspection. B. System Conditionally Passes: N/A ' One or more system components as described in the"Conditional Pass"section need to be replaced or p eP 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: 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 ND explain: tThe 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: t r ' Page 3 of 11 ' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 1326 Main Street,Cotuit Owner:Richard&Ngaire Cuneo Date of Inspection: July 7,2001 ' C. Further Evaluation is Required by the Board of Health: N/A 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 that no other failure criteria are triggered.A copy of the analysis must be attached to this form. ' 3. Other: f ' Page 4 of 1 I ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) ' Property Address: 1326 Main Street,Cotuit Owner:Richard&Ngaire Cuneo Date of Inspection: July 7,2001 ' D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: ' Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ' clogged SAS or cesspool— X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ' = X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow X Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 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 form.] ' No (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: N/A 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 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. ' Page 5 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B CHECKLIST ' Property Address: 1326 Main Steet,Cotuit Owner:Richard&Ngaire Cuneo Date of Inspection: July 7,2001 ' Check if the following have been done.You must indicate"yes"or"no"as to each of the following: ' Yes No X Pumping information was provided by the owner,occupant,or Board of Health(Sewage Treatment Plant) X Were any of the system components pumped out in the previous two weeks? 1 X _ Has the system received normal flows in the previous two week period? ' _ X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) N/A X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? ' X _ Were all system components,excluding the SAS,located on site? _ X 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 ? Cesspools Only on-site) ' X _ 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 i X Existing information.For example,a plan at the Board of Health. X _ 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)] Page 6 of 11 ' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION ' Property Address: 1326 Main Street,Cotuit Owner:Richard&Ngaire Cuneo Date of Inspection: July 7,2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gad(assumed) Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use:(yes or no): Yes Water meter readings,if available(last 2 years usage(gpd): 1999-sK gals.(21.9 gaWdav).2000—5K gals.(16.4 galsJdav) t Sump pump(yes or no): No Last date of occupancy: Currently occupied. COMMERCUL411DUSTRIAL N/A ' Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq ft,etc.): ' Grease trap present(yes or no):T 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 Source of information: No pumping records available Barnstable Sewage Treatment Plant) ' Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system X Single cesspool ' X 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown age of cesspools Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 IL ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 1326 Main Street,Cotuit Owner:Richard&Ngaire Cuneo Date of Inspection: July 7,2001 ' BUILDING SEWER(locate on site plan) Depth below grade: 6" ' Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): ' No evidence of leakage,all ioints appear to be in good condition on the day of inspection. SEPTIC TANK: N/A (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 battle: _ 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: N/A (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.): 1 t ' Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 1326 Main Street,Cotuit Owner:Richard&Ngaire Cuneo Date of Inspection: July 7,2001 ' TIGHT or HOLDING TANK: N/A (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/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: N/A (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: N/A (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.): Page 9 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Property Address: 1326 Main Street,Cotuit Owner:Richard&Ngaire Cuneo Date of Inspection: July 7,2001 ' SOIL ABSORPTION SYSTEM(SAS): N/A (locate on site plan,excavation not required) ' If SAS not located explain why: Type leaching pits,number: 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.): CESSPOOLS: X (cesspool must be pumped as part of inspection)(locate on site plan) ' Number and configuration:2 Cesspools in line with each other(discharge is to 1 cesspool which discharges to 1 overflow cesspool. Depth—top of liquid to inlet invert: Cesspool No 1—None present,Cesspool No 2—None present. Depth of solids layer: Cesspool No 1—None present,Cesspool No 2—None present. Depth of scum layer: Cesspool No 1—None present,Cesspool No 2—None present. Dimensions of cesspool: Cesspool No 1—6'x 6'(no stone),Cesspool No 2—6'x 6'(with 18 inches of stone all around). ' Materials of construction:Cesspool No 1—Brick,Cesspool No 2—Precast concrete. Indication of groundwater inflow(yes or no): No Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Soil was found to be dry around both cesspools. No ponding was noted in either cesspool. No lush vegetation ' was encountered at either cesspool. PRIVY: N/A (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.): r ' Page 10 of 11 ' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 1326 Main Street,Cotuit Owner:Richard&Ngaire Cuneo Date of Inspection: July 7,2001 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. I ' Please see attached sketch 1 1 1 1 ' Page 11 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 1326 Main Street,Cotuit Owner:Richard&Ng afire Cuneo Date of Inspection: July 7,2001 ' SITE EXAM Slope: Mostly flat in SAS area. Surface water: Cotuit Bay is located to the east ' Check cellar: No water Shallow wells: None in area Estimated depth to ground water 15 feet(below the ground surface at the SAS) ' 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: Checked with local excavators, installers-(attach documentation) ' X Accessed USGS database-explain: You must describe how you established the high ground water elevation: 1 Seasonal high groundwater was determined by comparing USGS/Cape Cod Commission groundwater data and Town of Barnstable GIS data to field measurements. ' The surface of the ground at the SAS was estimated from the Barnstable GIS map (June 1992) to be at elevation 20. The bottom of the deepest cesspool was measured to be approximately 8' below the surface; therefore,the of the bottom of the SAS is at elevation 12, The groundwater elevation beneath the site was estimated from the Barnstable Ground Water Contour and Road Index Map(June 1992) and found to be at elevation 3.5. Using the Cape Cod Commission method to ' estimate the seasonal high groundwater elevation, the site was found to be within the area of groundwater indicator well MIW-29(Zone A). According to the data available from the Cape Cod Commission the June 1992, the adjustment for that well is 1.8' upward. Therefore, the adjusted groundwater is at elevation 5.3. 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"f as✓� 14 f�. � !!! ...... � .. �,�, Meadow` It � � a s \�,/£ Thatch i r �,Y island I` ' Name:COTUIT Location: 041'36'42.3" N 070°26'10.9" W Date:7/9/2001 Caption: Locus Map Scale: 1 inch equals 2000 feet 1326 Main Street Cotuit, MA. 1 Septic System Sketch 1 1 i are q 1 M 1 A I 1 N Cesspool 2 1 50' "1 S ' T Cesspool 1 1 R 34' 32' E 1 E T #1326 William E. Robinson, Jr.Location: 1326 Main Street Figure 2 ' Septic Inspections Cotuit, MA. 43 Tomahawk Drive Not to Scale ' Centerville, MA. 02632 Date: July 7, 2001 Based on Visual observations 1 1 1 1 1 Inspectors Certificate t 1 1 1 11 I ' fw * G W t THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT `William E. Robinson, Jr. j 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. April 20, 1995 Ct Acting Director of the Mon of Water Pollution Control 1 1 1 1 1 1 1 1 i � 1 1 1 1 1 � � 1 LOCUTION . SEWW:C E PERMIT UO. iWSTA E •5 M UDDRESS BUILDER 5 t.J L VAF- P, ADDRESS DQ''E PERW-T ISSUED •— — — — 14 D s.TE COMPLI W ICE ISSUED - — — — 1 P .:-,ham. 1 r\^�p`�\�y P T,}. � u ..., I� `1 1 � t�„� .� as .�� (,� f -. r �d�'��. .�,� :- No. ....."......... Finz........a.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Lf/1-z.. OF.............'Or! .. ...... ................ Appliration -for Di_q oiitt1 Works Towitrortioo Ppriud Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual .Sewage Disposal System at: Wi _ t.-_ -................................... 6_ ._ '`- = ----------------- . .. '71..!......on�A ress or o o. O ddress . . e__. _.. --•••--•--•--- Installer Address Q Type of Building Size Lot----------------------------Sq. feet U Dwellingjbel�o. of Bedrooms______________________________ _____________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building __________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures --------- -----------------------= - W Design Flow--------------------_______________________gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width.-_-_-_-----. Diameter---------------. Depth----------._.--. x Disposal Trench—No- -------------------• Width-------------------- Total Length.................... Total leaching area...............-----sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area------ -----------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by----------------------...........................................-------- Date------------------------ -------------- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...--------._...__----- �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-.._-.--._._---_.---- P4 ----------------------------•------•---•--------'-'•----•-'-...................._•----•----••••--...'--'-'•...-••-...•------------------------------------- ODescription of Soil---------------------------------------------'---------'------------------------------........----------------------.....---------------------------------------------- x W ------------- ---------- ------------------------------------------------------------------------------- ----- -------- UNature f Repair or A er< tons—Answe en applicable... __ . _.._.__________._.�__.._.___�________________ ________ ____________- -- . -- -- . - -- --------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is d by the board f heal Signe SY��-c -----------•----- Fw �- Application Approved By----- - �--------------- --- ----- 7" Date Application Disapproved for the following reasons:----••.........................V.......................................................................... Date PermitNo......................................................... Issued.--A_-N-6-------76-----•------------------- Date 1 e I M1 ��• ii Ali . :rs � � i�V � 1 �G�._____--�...._.._... `�y1' v � __---- � � �..� .�--.-----_.."" it ._..--- _.-.--_ �-- �_ _ .---� . �• 74- No......................... Flmic........ ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - -------OF..............2 - ...... Applirtttion -fur Biipuuttl Workii Tomitrortiuu Vrru it Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System - ---- - --- --- �/ jj Loc�tion:A ress or Lot No. � -�J ........`i,......•... .. ...• ---------- ------ ........------------------ -•----•-- A / O ne• "y, - Address Installer Address UType of Building Size Lot-.-_----------------------Sq. feet Dwelling��No. of Bedrooms--------------------------------------------Expansion Attic (, ) Garbage Grinder ( ) per, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow--------------------------------------------gallons per person per day. Total daily flow........................-_-.--------.-----..gallons. P4 Septic 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. fi. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date------------------------------------.--- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-._----------.--_.--.--- (� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water----.-.--__-----_---.._. ------------• -------------• - •-••-•-•-•------------------•-•--•-----•-------••-----••------•-----...................................................... 0 Description of Soil---------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ x U ------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W ------------------------------------------------------------------------------------------------------------- = ------- ..... V Nature ,.f Pepair or Al er ions—Answer when applicable.-.. t -6..._J--------------------_ U f �..--- - lz -------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the board-of heal i. jf _ Signe /. ---- ( - f 1/ Date Application Approved BY---- -- ------------- v/,l /�-�.1 Date � Application Disapproved for the following reasons________________________________V -----------•----•---•-•----------------------- --•----------- •--.......--•-•-----•-------•---•--•-•--..._...--•--------•-•-•---------•-•-•----------------------------------------•••----•.....-••--•---•-•--•---•------•-----------------•---------------------- _P41E. Permit No........................................................ Issued.-�` 6 ------------- Date. THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 F HEALTH !i< ........OF.......jc. /�!!-� .,..r ......... ................. Trrtifirttte of TOmpliaurr THI. 0 C RTh the Individual Sewage Disposal System constructed ( ) or Repaired (� -- ---- -----7with Y --------- - - ns l e f /� - has been installed in accordane rovisions of . rticle XI of The State Sanitary C-Jde as described in the application for Disposal Works Construction Permit �.� r�................... dated.__.--.--> -..7 ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... -------------------------------...................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS 07t� i BOARD O HEALTH l ,/Lr..............of........ .. .......--------- --.......---... P40......................... FEE--- ...................... � rtivat �rrutit ... Permission is hereby granted - t --------------------------------.......................................... to Const >ft ( ) o�'��Repair ( Indjv•clual Sewa - Disposal S t / at No.'.., •-•�. .r.---- . ..-�- ...42.-'t'R'=. -- `' ^< ------------------------------•--- Street _ as shown on the application for Disposal Works Construction 'e m i t N ,f.. .r�1------- Dated----------------------7S'_-------- (> _ - , �( � .lv� -/� ---------------------------- ' DATE...........—S-- iJ`� Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ___ __ _ �� i � ,/^' ^ / � - a �� .. �,