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Home My WebLink About1331 MAIN STREET (COTUIT) - Health 1331 'Main Street, Cotuit it i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1331 Main St. Property Address f,� Delorey ; Owner Owner's Nine information is ✓ required for every Cotuit MA 02635 7/31/19 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. A. Inspector Information 6y0- N030 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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 16.000); 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 4z(d4�_ 7/31/19 Inspector naturlli 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_notaddress how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner information is Owner's Name required for every Cotuit MA 02635 7/31/19 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: All pumbing tied into this system per 1997 compliance and homewoner 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 18 l Commonwealth of Massachusetts re Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner information is owner's Name required for every Cotuit MA 02635 7/31/19 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.7/2 612 0 1 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I ' Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 1331 Main St. qiw� Property Address Delorey Owner information is Owner's Name required for every Cotuit MA 02635 7/31/19 page. Cityrrown State Zip Code Date of Inspection G. 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 El ® 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 ,. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner information is owner's Name required for every Cotuit MA 02635 7/31/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® 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 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner information is owner's Name required for every COtuit MA 02635 7/31/19 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 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner Owner's Name . information is required for every Cotuit MA 02635 7/31/19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): n/a Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: No engineering available at BOH, 5 bedroom per 1997 compliance on file Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: ' Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 f Commonwealth of Massachusetts 9Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner information is Owner's Name required for every Cotuit MA 02635 7/31/19 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: No pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner information is Owner's Name required for every Cotuit MA 02635 7/31/19 page. City/Town 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): Approximate age of all components, date installed (if known)and source of information: 1997 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18„feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1331 Main St. Property Address Delorey inform Owneration is Owner's Name required for every COtuit MA 02635 7/31/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appaers to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 10" 11 Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 1/2 >211 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle ,211 How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system, 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1331 Main St. Property Address Delorey inform Owneration is Owner's Name required for every COtuit MA 02635 7/31/19 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �a 1331 Main St. Property Address Delorey Owner information is Owners Name required for every Cotuit MA 02635 7/31/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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): offDepth 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.): H-10 d-box is 2' below grade and in very good condition t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner information is Owner's Name required for every Cotuit MA 02635 7/31/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: 6 per as built ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o 1331 Main St. Property Address Delorey Owner information is Owner's Name required for every Cotuit MA 02635 7/31/19 page. Cityfrown 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.): The leach pit was video inspected and the effluent is approximately 12" below the invert at this time, the chambers were video inspected, they are served by a hung pert pipe, no indication of past hydraulic failure or any high staining in the pipes, top of chambers is 2'6" below grade 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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 Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner Owner's Name information is required for every Cotuit MA 02635 7/31/19 page. Cityfrown 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 18 I Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner information is Owner's Name required for every Cotuit MA 02635 7/31/19 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 E Ll t TOWN OF BARNSTABLE Q LOCATION13��I ►-&-� SEWAGE# VII LAGS Q `v, ASSESSOR'S MAP dt LOT INSTALLER'S NAME&PHONE NO.�3•17A.A//j�.- 41M—SYO?9 SEPTIC TANK CAPACITY 100.060I _ EACHING FACELM: t 6 Cv/TeC 33z (si.) Lf t AJ'F e NO.OF BEDROOMS h� BUILDER OR OWNER I. Q DeLlOftj PERMITDATE:_y."1 1qq7 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 Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facilit�) Feet Furnished by. UK OU101 ilot 611 a- t30k .a 3 r 57 tT low � is �.p .-BOX e i I ' Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1331 Main St. Property Address Delorey Owner information is Owners Name required for every Cotuit MA 02635 7/31/19 page. Citylrown 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: >12 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: n/a Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 1997 compliance on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping You must describe how you established the high ground water elevation: See above 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 L_ r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1331 Main St. Property Address - Delorey Owner information is Owner's Name required for every COtuit MA 02635 7/31/19 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 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 r ....._.. .... _ _._ , ...... . . . _m_. ,W._...,..... ...... _ ^_ . TOWN OF BARNSTABLE LOCATION � � I g�N ST, SEWAGE # 1 7'3Sa VILLAGE CaT� ."T ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY L DO6 GH LEACHING FACILITY: (type)'A T-f 6 Cgrre C 33® (size) IW t ><oV e b NO. OF BEDROOMS S BUILDER OR OWNER l• i'7 DeLolftl PERMITDATE: COMPLIANCE DATE: t.. 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 Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by (pit D. i3ovi_ ;a 3 17' 1 l Y0 7 0 ` Coa rnorlweatth Of M=ochusetts ExecutNe Office of EnWonmentol Affolfs Department of Environmental Protection wWlarn F.wow Trudy Cosa �ao» &---y Aryw Paul Wuocl David B.Struhs LL Gowns Syr g 9 d0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0 CERPTIFIC.ATION REcEl VFP �! Property Addreeer 1331 Main Street C o t u i t,Mass . Address of 0 J U N 10 1997 Date of Impeotloa: 5/23/97 (If different) TOWiuOFg Name of Wpeotor. Joseph P.Macomber J r. HEALTH DEPT. Company Name,Address andpTelephone Number. J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 0263 CERTIFICATION sTATEMENT 508-775-3338 s 10 I artity that I have personally inspected the"wage disposal syrtam at this address and that the laformttica reported true,aoauvu and complrts as of the time of inspection. The inspection was performed bald on my training and experience in the proper function and mainteaaac»of onaite sawage disposal systems. The system: _ Passes Conditionally Pass" Needs Further Evaluation By the Local Approving Authority lmspectot'e Signatures The System Inspector+hall submit a copy of this iaspecah report to the Approving Authority within thirty(30)days of completing this inspection If the system is a A-M system or has a design glow of 10,000 gpd or greater,the inspector and the system owner shall suhmia the report to the appropriate regional office of the Department of Eavimamsatal Protection. The original should be seat to the system owasr:tad copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: �(� q 7 14St, Check A. B, C,or D: 67I(97 A) SYSTEM PASSES: ov�tTD o g oO- A,� I have not found any Information which Indicates that the system violates any of the failure crit4 'as d4 ned in 310 CUR 15on Amy faDure criteria not rvaluatd are indicated below. rut B) SYSTEM CONDITIONALLY PASSES: One or more syrtsm components need to be replaced or repaired. The rystaa,upon Completion of the replacement or repair, paasse Indicate yea, no,or not determind(Y, N,or ND). Dwrlo basis of determination in all instance.. if-not determined',=plain why not) A10 The"Ptic tank is metal, cmzked,structural),unsound,shows subetantW infiltration or ezSltratio n..or task faDure L imminent. The system will pea inspection if the existing spptic tank Is replaced with a Donforming septic tank as approved by the Board of Health. (rav(sed 11/03/95) 1 One Wint*r Street a Boston,Massachusetts 02106 a FAX(517)SWI0649 • Telephone(617)292•5500 t�hind on ROCVCW►&PW SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(000tinuod) Prop.rtywddr..a: 1331 Main Street Cotuit,Mass . Own" John Murry Date of LwP"tloar 5/2 3/9 7 B)SYSTEM CONDITIONALLY PASSES (coat(auad) ti41L� Sewae backup or bmkout or ho static water level observed in the di�trtbuiloa bos�is duo to b:olua or obstruct4d piper or due to a broks4 settled or uarvam distrbAion boa. The systam will pass bupsaloa if(with approval of the Board of Health): . broken pipes)ere replaced . obstruction is removed distribution box is livened or replaced The gstam required pumping more than four times a year due to bsokea or obstructed pips(s). The system wiU pans tupection if(with approval of the Board of Health): broken pipe(s)are repUcod obotr u tion is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTHr -ft Conditions mist which require furtber evahtation by the Board of Health is order to dete udw if the syetam is Ealing to protect Lbe public heakb,safety Lad the eaviroamsat. 1) SYSTEM WILL PAN UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING W A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND TH3B ENVIRONMENT 421 Cesepool or privy is witbia 60 fact of a surface water 42 C«spool or privy is within 60 est V a bordering vegetated wetland or a rah marsh. 3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 18 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HYALTe AND SAFETY AND THE ENVIRONMENT. g?p The system has a septic tank Lad sol absorption system and is within 100 feet to a surface water supply or v%butary to a surface water N➢pb• The system has a septic tank and sol absorption system and Is within a Zoos I of a public water supply well The system hu a septic teak Lad col fbwrptioa system Lad is within 60 feet of a privets water supply wail .G The system hu a septic tank Lad sol absorption system and Is lass than 100 feet but 60 feet or more tiom a privau wear su➢➢b'wall,unless a well water aaalyais for wUorm bacteria Lad volatile orgaak oompounds indimt,"thu the w%U is tie. bvm polhrtiom JMM tbat fLdUty and the preeaace of ammoaL nitrogen Lad nitrSt aitroaea is equal to or 6es than 6 ppm 3) OTHER (revised 11/03/95) _ i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Ptop,rtyAddro,,s:1331 Main Street Cotuit,Mass . Owners John Murry Date of Inspection: 5/2 3/9 7 D) SYSTEM FAILS: I have determined that the system Violated one or more of the following failure criteria as defined in 310 CUR 16.303. The basis fox this determination is identified below. The Board of Health should be contacted to determine what will bs necessary to correct the failure. Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the wound or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution bans above outlet invest due to as overloaded or clogged SAS or cesspool. i Liquid depth is oaespooI is Is"than 6'below invert or availabk.whrme_L-lass-than V2 day now. Required pumping more than{timed in the last year NOT due to clogged or obstructed pipe(a). Number of timed pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation CIO 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 Is"than 100 feet but greater than 60 feet from a private water supply wall with no aooeptable water quality analysis. If the well has been analysed to be acceptable,attach copy of well water analysis for coliform bactaria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: 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 signiScant threat to pub health and safety and the environment because one or more of the following conditions a3st. the system is within 400 feet of a surface ddalsing water supply the system is within 200 feet of a tributary to a surface drinking water supply the system L located in a nitrogen sensitive area(Interim Wallhead Protection Arse(IWPA)or a mapped Zone 13 of a pub. water supply"ll) The owner or operator of any such system shall bring the system Lad facility into AM compliance with the groundwater treatment props= requirements of 314 CMX 6.00 and 6.00, Pleass consult the local regional,office of the Department for llutbar information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC77ON FORM PART B CHECIO.IST Property Addr*" Ownart , Date of iarpootlow • Chad:if the Wowing bave been,don•: !' Pu,Pi,i information was toque"of the o occupant,and Board of Health. Lb y None of the eystem componag-have bee=pumped for at least two weeks and the system has bee=reoeiviAg normal slow rau during that Period. Lams volumes of water have not bee=introduoed into the system rroeatly or u part of this Iti built plans>ar.been,obtained and ezamin,ed ''Non,if they are act hvaileble- i"'N/A. ZTha facility or dwelling was inspected for sips of"wage back-up. T z7u eysNm does not reoetve non•sanitary or industrial waste Dow „9Tha site was inspected for sips of breakout. t+,446udiag the 802 Absorption System,have been located on the site. • The septic tank manholes ware uaWvarod,opened,and the iaterbr of the septic tank was inspected for condition of be or tees,material of construction,dimatisiow,depth of liquid,depth of slud&%depth of scum �al"and location of the Boil Absorption System on,the site has been,detarminad based on nistin8 iafosmation or •y by aoa•latruaiw methods. The facility owaar(sad oowpsats,if diSer+eat Surface Disposal System. from owner)were provided with iaformaxfoa on,the Proper maintenanceof Sub (revised 11/03/95) �l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:1331 Main Street Cotuit,Mass . Owner: John Murry Date of Inspection: 5/2 3/97 FLOW CONDITIONS RESIDENTIAL: Design flow: p. droom 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):-d.)2 n/� Water meter readings, if available (last two (2) year usage (gpd): 6� /. , Sump Pump (yes or no):_,VQ IMF- Al Z�6 Last date of occupancy: ram^/ 7 COMMERCIAUI N D USTR IAL: Type of establishment: zlJ 4 Design flow: YJi+;7 Rallons/day Grease trap present: (yes or no)&,?,4 Industrial Waste Holding Tank present: (yes or no)�/Q Non-sanitary waste discharged to the Title 5 system: (yes or no)_0 Water meter readings, if available: 4 Last date of occupancy: OTHER: (Describe) 1 Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS d so rce f information: l System pumped as part of inspection: (yes or no)� S' If yes, volume pumped: allons Reason for pumping: TYPE OF>'YSTEM Septic tan soil absorption system Single cesspool A�b Overflow cesspool ,0{P Privy A)19 Shared system (yes or no) (if yes, attach previous inspection records, if any) _,VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 5 mat' 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: 1331 Main Street Cotuit,Mass . Owner: John Murry Date of Inspection: 5/23/97 SEPTIC TANK: /0 X-V e , (locate on site plaN Depth below grade._ '7 > — — ►vtaterial of construction:/concrete _metal FRP other(explain) Dimensions_ ` Sludge depth: Distance from top of dge 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._ Comments: (recommendation for pumping, condition of inlet and outlet tees or bafflet. depth of liquid IPvel in relyorkto outl t )nve w Ural rity, evidence of leakage, etc.) Pumpseptic tank ever 2-3' ears : n et C outlet tee� te in place : Tank is s ructura ly sound: The-TanK snows no _ ZZ gn.g n l P pka g Pew GREASE TRAP.44A4- (locate on site plan) Depth below grade:�/.� Material of constrairtion; zonc(ete _metal _FRP_other(explain) Dimensions,• Scum thickness._ Distance from top vs scum to top of outlet tee or baffle:_4� Distance from bottom nt srum in bottom of outlet tee or baffler_2J Comments: (recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, et Grease rap is not presen (revised 9/15/9$) 6 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) propertrAdd,,.c 1331 Main Street Cotuit,Mass . own"; John Murry D&W of Insp.otioa: 5/2 3/9 7 TIGHT OR HOLDING TAMi',&A- . pocate on sit•plan) • Depth below�mde:•yJ1 Mat.sial of construction:1 ,portal ARP_othsxs:plmia) - �l� u Dimaasions: AM Gpmcity: Alarm level: Comments: (condition of inlet tee,condition of alarm mad float switch",etc.) lignt or Holding TanlM are not present. DLSTRIBLMON BOX_4,04,f, Uocate ca sits Plan) Depth of liquid level above outlet invert: ly/ Comman": (sots if 1evl and distribution is equal,evidaaa of solids carryover,evidence of leafage law or out of box,eta) Distribution box is not present. PUMP CHAMBE& QOcats an site plan) Pumps is working orden(yes or no) Comments: (zaa condition of pump chamber,condition of pumps and appurtensaces,etc.) Pump chamber is not present. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(wotiaued) P,,op,�Add,..i 1131 Main Stree Cotuit,Mass. Ow"n John MUrry Date of LwPovuaw5/2 3/9 7 SOIL AMRpnoN sysm csAsx Ooo.te W site plea,9poodbL;aeay.tioa not t�quk4 buc my be apprazim"b7 am4ubu.fv.mrtnob) It as datarmta.d to be prwat,=*in. Yypa U"1510 an.mbaM pDaied ykambe 6MININ trSACh4d, 9VW1W.aaapoo>,W= w ra Commaata:(ao(A oaadltioa of&oil, &J�p&of ludrsulia failasa,Laval of pondin&condition of veg.t&doz6.to.) None of the above are present. CESSPOOL9t Go="am du pi+a) � NumDar and ooaedaration: I DwrA-top ad 23gttld to Wid D94 of so"lyar. DsA of eaten l+V= Dimaa+done of oaaspooL- ldatariaL al ooa:avetioa: Indication of pwadWSUr. WAQW 1 (p be ,pan at o Con—U (note coadition of eoi1.sigu of lydrsul U%^I"of yondia�o rd tloa of yr 0 , . -Loamy sand to fine sand: The sign bt Y�yClraulic ai ure is present. The Tho 6i'aCt.P wst.p�r is .,.O n be-Low the invert pipe . No level of ponding all vegetation is normal. System must e upgra e 717h PWW, d L a new leaching area. Qoow as she PU4 l4tar(aL of al/S� Dapd of eo2ideax��CL - CommraL:(Dote ooaditioa of&4 s�pj of lydraulk 6. woe level of poadi4 condition of"W.At itc.) Privv is not presen (rrvlea0 11/03/9S)• + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks. or be ks r locate- al1---well-s---wi-thin---100' I'I - --- ---- - Gvtui - ten- Company 428-2687 DEPTH TO GROUNDWATER depth to groundwater P thod of determin4ion or approximati,ox�: I sta ,'L-. - . .IS �s 3t ai`ri. eea' :�ot-u t.-Pbrm-it # 91 -539 88 Ma n S ee o. ui : :.�.r� v 8'"Main _Scree �:rr ree o. 7 - xx ain ,er ecoereaStreet Cotuit a-t any oi these _: locations. All fine sand. rwwn*►.—n.•t�t—•n—mraw•t+.tw..r7.n wrn+�rwrs�.++rw►.►v.�.+w�rwn,�u+.rwT�rtw•et .. �T., TOWN OF Barnstable BOARD OF HEALTIr SUIISURFACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ��•TI'1R•.•::r•Rtt71�•T.TTT�II T.'fr1TA1r1RVTRrT.r—•i T'1VnR��f-TPR.�11�f't ,�w . -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 1331 Main Street Cotuit,Mass . t ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME John Murry" PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber. & Sofi` Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State it COMPANY TELEPHONE ( 508) 775 - 3338 FAX ( 508 ) 790 - 1578 w CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system this address and that the information reported is true , accurate, and complete as of the time of .inspection . The inspection was performed and anyl recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of o ' site sewage disposal systems . Check one: System PASSED _ The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section ofi this form. CXXXXXXXXXXXXSystem FAILED# The inspection which I have con cted has found that the system fails t 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 or this inspection form . Inspector Signature Date 5/23/97 .ttx2rV1=„W1W One copy of t11is certification must be provided to the OWNER the BUYER( where applicable ) and the BOARD OF HEALTH. ' • If the inspection FAILED, thb owner or"operator shall upgrade within one year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 CMR 16 . 305 . partd .doc U 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. June 9. 1995 ' Acting Director of the ' ion of Water Pollution Control f TOWN OF BARNSTABLE Q LOCATION SEWAGE # VILLAGE CcTy ,,-T _ ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO.,/1A04.,111�e.� yM 5Y07 9 SEPTIC TANK CAPACITY ®®OGAI -EACHING.FACILITY: �a-r+- 6 CvI7'� (size) t �i rt C �_ (h'Pe) _ (size).!—.. j , NO.OF BEDROOMS BUILDER OR OWNER / 6 _Deb' "" 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 Wetland and Leaching Facility(If any wetlands exist n within 300 feet of leaching facility) Feet Furnished by _ 0 s C,X O ;I G � $ yr No. 070�`' �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Diopogal *pgtem Construction Permit Application for a Permit to Construct( )Repair(Y)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. t%.\ 's-T, Owner's Name,Address anp Tel.No. Assessor's Map/Parcel Q0_561 es � ��A� c l oecr Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. GO(uJo1,- I'sQr\-,?Us Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) AQ/) 0Z.17 Ao x — X'+ Cy�C 330 S /% " 5 T--(r - 316:57-017 2 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is;rr-e- by thi ;�Uian f ky Signed � . Date M.,1 11 / 7 Application Approved by Date -7 - 1(_ 9 Application Disapproved for Me following reasons Permit No. 7 3s Date Issued ,( 4 No. /' Fee -THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 _ Yes PUBLIC'HEALTH DIVISION--TOWN OF,BARNSTABLE., MASSACHUSETTS= Y 2ppricatiott.for Miopoal *pgtem Couttruction Permit Application for a Permit to Construct( )Repair(/l)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and d Tel.No. gel Assessor's Map/Paicel a CO l U l • Installer's Name,Address,and Tel.No. 11d 8-56 y0 Designer's Name,Address and Tel.No. Gocz�� 3��.�Us cV5— Type of Building'.. No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other.' Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures —- ; u t+ t C, Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil k Nature of Repairs or Alterations(Answer when applicable) 4,00 0/S77 / y� 3T xir - 3/& sione; Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this Board a Healt Signed %� GGGc- /F�GG' Date T-1- Application Approved by %--!V 'Date -7 Application Disapproved for&el foll;wing reasons 35 Permit No. V 7 3.S 2 Date Issued / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( 111 Upgraded( ) Abandoned( )by at 1331 "A,", S-r, COTv",-T has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. /�� dated Installer Designer The issuance of this permit shall, t be costrued as a guarantee that the system will function as des gin dl. Date V I Inspector �`.�` �I�, �✓ti !/f.'� h�: --------------------------------------- -el No. 2— Fee \_ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1wigoogar *pgtem Congtruction Permit Permission is hereby granted to qcnstruct( )Repair( KUpgrade( )Abandon( ) System located at 1331 R ST Cn`r 41.'T and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: 7 - 7 Approved by NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, 0 20o,x"BUn^ U�S, hereby certify that the application for disposal works construction permit signed by me dated�`�� c l q S,2 , concerning the property located at Co- meets all of the r: following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: LICENS SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified.plot plan, this plan should be submitted]. CC>U�2� i T max 14 ee -7�6 S 70,g e Co vc2