HomeMy WebLinkAbout1391 MAIN STREET (COTUIT) - Health 1391 Main Street (Cotuit)
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DATE: 12/29/01
PROPERTY ADDRESS: 1391 Main Street
Cotuit,Mass.
------------------------
02635
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1500 gallon septic tank.
2. 1 -Distribution box.
3. 2-1000 gallon precast leaching pits. ( 6 'X10 '
Based on my Inspection, I certify the following conditions:
4 . This is a title five septic
pt c system. ( 78 Code )
5. The septic system is in proper working order
at the present time.
6. Both of the leaching pits are dry.Stain lines show that
the leaching pits have never been full.
7. System is adequate for a five bedrooms.
8. There is at least 2-22 feet of stone all
around the two pits. SIGNATURE:s' _J. &�+
Name:_,L,p _ Macomber _Tr,______
Company: Joseph-P. Macomber,& Son ; Inc .
Address. Box 66
--------------------
Centerville , Ma . 02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
•
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachfleids
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
.775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
U9
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS,
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 1391 Main Street
Co uit,Mass.
Owner's Name: Carey &* Grover
Owner's Address: Same
Date of Inspection:
Name of Inspector: (please print) J.P. Macomber Jr.
Company Name:Joseph P. Macomber & Son Inc
Mailing Address: P.O. Br)x 66
rent er-ille Ma. 02632
Telephone Number: 508-775-3338
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:
�1Passes
_ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: ;"
The system inspector shall s bmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****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.
I
Title 5 Inspection Form 6/15/7000 page 1
Page 2 of 11
, i 3
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1391 Main Street
Cotui ,Mass.
Owner: Carey & Grover
Date of Inspection: 12 29 01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys�Pa
I have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303'or in 310CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order
at the present time
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
'( The septic tank is metal and over 20.years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
•A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
46 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:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
i
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 391 Main Street
Cotuit,Mass.
Owner: Carey & Grover
Date of Inspection: 1 2/2 9/01
C. Further Evaluation is Required by the Board of Health:
�t 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:
NO 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.
4,0 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
W 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 eet but 59 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:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 391 Mian street
Cotuit,Mass.
Owner: Carey & Grover
Date of Inspection: 12/2 9/01
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no"to each of the following for all inspections:
Yes No
P"Aackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool 0Pe"4O VM'S G,�y-) ("K..ev "WAO,
iquid depth in.ce9,9peei is less than 6"below invert or available volume is less than 'h day flow
Re uired pumping more than 4 times
.q P P g to the last year NOT due to clogged or obstructed pipe(sj. Number
f times pumped (1 .
1/4 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,
Fkny
y portion of a cesspool or privy is within a Zone 1 of a public well.
y portion of.a cesspool or privy is within 50 feet of a private water supply well.portion of a cesspool or privy is less than 100 feet but greater than 5.0 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.)
4)D (Yes/N.o) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR-15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: _
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
elt e system is within 200 feet of a tributary to.a surface drinking water supply
v the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 391 Main Street
Cotuit,Mass_
Owner:Careyr & Groyt-
Date of Inspection: 1 2.12 g f Q 1
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes Now
Al Pumping information was provided by the owner, occupant,or Board of Health
6' 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?
t/ _ 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 componencs,,�€luding the SAS, located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
Ke baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum?
_I/ 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 o
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 I5.302(3)(b))
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 391 Main Street
Cotuit,Mass.
Owner: Carey & Grover
Date of Inspection: 1 2/2 9/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): h Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):.
Number of current residents: lX
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system yes or no); [if yes separate inspection required]
Laundry system inspected( es or no):
Seasonal use:(yes or no):A.15
Water meter readings, if av 'lable(last 2 years usage(gpd))
Sump pump(yes or no): AZ
Last date of occupancy:
COMM ERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): zDd
Basis of design flow(seats/persons/sgft,etc.):_
Grease trap present(yes or no):"
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:J�—
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
f
Source of information: �! `� �J�•� (�?�� ,,�,r��'
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped:6 go ns--How was quantity pumped determined?
Reason for pumping:
TYP 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 syste owner)
Tight tank Attach a copy of the DEP approval
/Other(describe): .�✓1�'
Ap roximate oe all c ents,d installed (if kno and�� ce of information: ~mil
AA el
_L1*1
Were sewage odors detected when arriving at the site(yes or no):
6
1
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 391 Main Street
Cotuit',Mass-
Owner: Carey & Grover
Date of Inspection: 2,129/D1
BUILDING SEWER (locate on site plan)
Depth below grade: . �
Materials of construction: cast iron j/40 PVC4/bothe explain):
Distance Erom private water supply well or suction line: Zc -
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear ti,9-4 .N.o evidence of leakage- The System
is vented through the house vents.
SEPTIC TANK: /locate on site plan) /f A 571' r/0 '.
Depth below grade: �
Material of construction: ✓concrete,bmetal4�d fiberglass polyethylene
,IL6 other(exp)ain) /4M
if tank is metal list age:0 is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: `—04&
Sludge depth:
Distance from topoff Judge to bosom of outlet tee or bafe: .�t. ..�
Scum thickness: —�
Distance from cop of scum to top of outlet tee or baffle:
Distance from bottom of scum to boaom of outlet tej or baffle:
How were dimensions determined: Q/9
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage, etc.):
Pump the septic tank everk 2-3 . yparc Inlet & outlet tees
are in place.The tank is structurally sound and shows no
evidence of leakage.The liquid level at the outlet invert
is 51 "
GREASE TRAI' (locate on site plan)
Depth below grade:.
Material of con struction:,-concrete,meta lWAfiberglass4&±_po lyethylene4ALother
(explain):_ �i�
Dimensions: �i!?
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle:—
Distance from boaom of scum to boaom of outlet tee or baffle:. ./.1
Date of last pumping: 4/1#
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet inven, evidence of leakage, etc.):
C,rPaGa trap is note resent.
I
7
-Page.8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 391 Main Street
Co ui , ass.
Owner: Carey & Grover
Date of Inspection: 12/29/01
TIGHT or HOLDING TANK, (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:4�__4concrete,4.64 metal j14 fiberglass 4L4Polyethylene40other(explain):
Dimensions:_
Capacity: gallons
Design Flow: W4 gallons/day
Alarm present(yes or no): 4
Alarm level: V,4 Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
Tight or holding tan s are not present.
DISTRIBUTION BOX: Z(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.):
l)istrihntinn hnx has two laterals No evidence of solids
r'ar"r'y over No piri nano• of-leakage_ into or out of box
PUMP CHAMBERVAVE(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Pump chamber is not present
8
f
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 lA1 Mi�'i n st:=Qet
C'ot'lli f ,macs
Owner: Carey Gr-ni er
Date of Inspection: ,)g I Q i
SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required)
2-10
of 12" stone.
If SAS not located explain why:
Located; See page 10
Type
leaching pits,number:j
leaching chambers,number:
i�leaching galleries,number: 0
APleaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number: i ��--++
innovative/alternative system Type/name of technology f/Pt�v
Comments(note condition of soil, signs of hydraulic failure, level o ponding,damp soil,condition of vegetation,
etc.):
Loamy of h
or ponding Both nf the dry at th s t-=a=
Vegetation is normal.
ESSPOOL cess ool must be pumped as part of inspection)(locate on site plan)
C .( P
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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspools are
PRIVYdOd(A(locate on site plan)
Materials of construction:
Dimensions: ff
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation;etc.):
9
J
" Page 10 of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 391 Main Street
Cotuit.,Mass.
Owner: _Carey & Grover
Date of Inspection: 1 2'/29/01
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.
C>
M
E� O
Z,,Vt6l-Z
V Nt W 10S,IF7
i
10
Page 1 I of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1391 Main Street
Cotuit.,Mass_
Owner: Carey & GrovPr
Date of Inspection: 1 -9/2 g f n 1
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
e.
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obta' ed esi plans on record-If checked,date of design plan reviewed:
bserved site(abutting rope bservation hole within 150 feet of SAS)
_911ecked 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:
Used Cahrat-v Mi 1 1 er—Mode 1 1 2/4 6T 4 Ground watPY above sea 1 eixe
USGS Ohservatinn well data June-1992
USGS Annual rangPc of grn111ad yXatQ � An�I Plate#2
Tup of Ground
Leaching
Pitt
Groundwater:9 feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bott
of the leaching pit and the adjusted groundwater table is
feet.
11
�v•.+.:,�T++.—..rr�+—.Tr-s.nrmr•r.srrrrnnren+gran-n.+e,�.r„+.•re,•,ern neray+..�rnersinn .. r .�I
TOWN OF Barnstable BOARD OF HEALTH �
SMISURFACR SFHAGR DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
•••Tf•t�T'•.•.• —T.t If.�.�1TI.T.T.f..'.T.'f!/I 7"R1r1RTTf1TT.'.1'.�.•.•T rR{RT.a.7.1C1"•T�RTR'.1R AT A
-TYPE OR PRINT CI,EARL1'-
PROPERTY INSPECTED
STREET ADDRES$ 1391 Main Street Cotuit,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Carey & Grbver
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME Joseph P. Macomber & Svn Inc
COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632
Street Town or City
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 08 790 1578 State LIP
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
' n i ili{ I
Chec one:
System PASSED
The inspection ;which I have conducted has not found any information
which indicates that the system fails to adequately protect public
he-alLh or Llie environment as defined in 310 CMR 16 - 303 ► Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED* \\
The inspection which I have con Acted has found that the system fails to
Protect the Public health and the environment in accordance with Title
5 , 310 CMR 15 .303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
r � -
Inspector Signature
Date ,
.;C=w -- -
ne copy of this rt.tfication must be
k ( where applicable ) and the 130ARD OF xEAiTovided to the OWNER, the BUYER
If the inspection FAILED, the owner or operator shall upgrade ' the system
within o'ne year of the date of the inspection, unless allow
otherwise as provided in 3,10 C�IR 15 . 305 ,
allowed or required
partd .doc
y 4.
-10�_
5�S S,Ci
W
Ul "
h1 3/7
THE COMMONWEALTH OF MA.SSA,CHUSETTS
DEPARTNENT OF ENVIRONWMNTAL PROTECTION
BE IT SOWN TEIA T
Joseph P. Macomber, Jr.
Has satisfied the Ike -
Department's quahficatzons as required and: -is hereby
authorlized to use the title
CERTEFIE}J TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A, o e
� f th
P
: General haws. Issued b - -
e De
y arooaen[ of Envuonme
� P ntal Protectzon_
2
Acing 06,mclog of the .on v( W�tct POVUllOfl Coouol
QY
DATE: 12/29/01----
PROPERTY ADDRESS: 1-391 _Main Street
- Cotuit,Mass.-----_-----
02635
------------------------
On the above date, I Inspected the septic .system at the above address.
This system consists of. the following:
1 . 1 -1500 gallon septic tank.
2 . 1 -Distribution box.
3 . 2-1000 gallon precast leaching pits. ( 6 ' X 10 '
Based on my inspection, I certify the following conditions:
.4 .. This ..is _a .tit.le five septic system. -(- 78-Code,') ..
15. The septic system is in proper working o'rder i
at the present time.
6 -.-Both of- the leaching pits are dry.Stain lines show that
the leaching pits have never been full .
7 . System is adequate for a five bedrooms. r
8. There is at least 2-2 '-2 feet of stone all
around the two pits. SIGNATURE:'
Name:_,.__ Macomber ,Jr�______
Company: JosejA_P_ Macomber & Son , Inc .
Address: Box 66
Centerville ;, Ma . 02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
rSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
•
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL, AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 1 391 Main Street
Co uit,Mass.
Owner's Name: Carey &* Grover
Owner's Address: Same
Date of Inspection:
Name of Inspector: (please print) J.P. Macomber Jr.
Company Name:Joseph P. Macomber & Son Inc
Mailing Address: P.O. Box 66
rantervillo Ma 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
l certify that 1 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:
Z/Basses 1
Conditionally"Passes
_ Needs Funher Evaluation by the Local Approving Authority
Fails G
Inspector's Signature: 41,d Date:7 4'
-D
The system inspector shall s emit a copy of this inspection report to the Approving Authority(Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design now 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
F'This report only describes conditions at the time of inspection and under the conditions of use at that
tithe. This inspection does not address how the system will perform in the future under the same or different
t conditions of use.
Title 5 Inspection Form 6/152000 page 1
Pase 2 of i I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 391 Main Street
Co ui , ass.
Owner: Carey & Grover
Date of Inspection: 12 29 01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: - �
I have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303 or m3 10 CI MR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments;.
f` The septic system is in proper working order
at the present time - -
B. System Conditionally Passes:
One or more system component as described in the "Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined" please `
explain.
Ve 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 back-up 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:
41) The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health).`
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
y
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 391 Main Street
Cotuit,Mass.
Owner: Carey & Grover
Date of Inspection: 1 2/2 9/01
C. Further Evaluation is Required by the Board of Health: t
�! Conditions exist which require further evaluation by the Board of Health in order to determine i_f the system'
is failing to protect public health, safety or the envirorunent.
I. 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
,60 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:
4)0 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.
4,V The system has a septic tank and SAS and the SAS is within a Zone. 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
w The system has a septic tank and SAS and the SAS is less than 1I00j eet but 59 feet or more from a
private Water supply well'•. Method used to determine distance�__�✓��L
*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:
3
Page 4 of 1 I
,
OFFICIAL INSPE
CTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 391 Mian Street
Cotuit,Mass.
Owner: Carey & Grover
Date of Inspection: 12/29/01
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no" to each of the following for all inspections:
Yes 2Aackup
of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid.level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool ,- ,g',(,A VM `S CG0r77 � x10 "W'.4t, -
�squid depth in.ce"peoi is less than 6" below invert or available volume is less than 'h day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
/Of•times pumped d
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 I of a public well.
✓_any portion of a cesspool or privy is within 50 feet of a private water supply well.
1/ 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.)
till (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ _ the system is within 400 feet of a surface drinking water supply
L-the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
eves" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
' 4
wb Page 5 of.1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 391 Main Street
Cotui ,.Mass_
Owner:Carey & ,rover
Date of Inspection: 1 0.12 9 /n 1 ,
Check if the following have been done. You must-indicate"yes"or"no"as to each of the following:
Yes Now '
4/ 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 breakout ?
s W
Were all system components,**eluding the SAS, located on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
Ke baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum ?
_I_ 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 o • •-
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(3)(b))
Page 6 of 1 1 .
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 391 Main Street
Cotuit,Mass.
Owner: Carey & Grover
Date of Inspection: 1 2/2 9/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(desi
gn):gn): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):
Number of current residents: _
Does residence have a garbage grinder(yes orno):4.4
Is laundry on a separate sewage system f yes or no);d_ [if yes separate inspection required]
Laundry system inspected(yes or no):20
Seasonal use: (yes or no):Ay `/
Water meter readings, if av�a�',lable(last 2 years usage(gpd)) _��
Sump pump(yes or no): A4
Last date of occupancy: _
COMMERCIAL/INDUSTRIAL
Type of establishment: ip
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or,no):
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as pan of the inspection(yes or no):—
If yes, volume pumped: ���ns-- How was quantity pumped determined?
Reason for pumping:
TYP 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 systejn owner)
/-L&2Tight tank Attach a copy of the DEP approval
Other(describe):
Ap roximate we all c ents, do installed(if kno and ce of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 391 Main Street
Co i ,MaG_ _
Owner: Carey & Grover
Date of Inspection: 12.129/01 '
BUILDING SEWER (locate on site plan)
�u
Depth below glade:
Materials ofconstmution: cast iron Z0 PVCR/bothFVexpIain): �U2A
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence 'of leakage. The sy_st= .
is vented through the house vents.
SEPTIC TANK: /locate on site plan) /�j00rj'J9 �
Depth below grade: 41111
�
Material of construction ✓ccncrete,CbmetaloOd fiberglass polyethylene
Nd other(explain) A7
If tank is metal list age:0 Is age confirmed by a Certificate of Compliance (yes or no)::/—/O(attach a copy of
cenificate)
Dimensions:l� �� .Gri' 17 /6 � ✓ /
Sludge depth:
Distance from top a ge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to !op of outlet tee or baffle: /Z
Distance from bonom of scum to bosom of outlet teg or baffle: _sue
How were dimensions determined:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet inven, evidence of leakage, etc.):
Pump the septic tank every 2-_3 . years`_ Inlet & outlet tees
mare in• place.The -tank is structurally sound and shows no
evidence of leakage.The liquid level at the outlet invert
is 51 "
GREASE TRAE(g(locate on site plan)
Depth below grade:leR
Material of coristruction:,(concrete,j�y metal fiberglass.f±yolyethylene4, other
(explain):�Jj9 `
Dimensions: 41W
Scum thickness: W
Distance from top of scum to top of outlet tee or baffle: AO
Distance from bosom of scu:n to bosom of outlet tee or baffle:
Date of last pumping: i(f/f —
Comments (on pumping recon:.me^da(aons, inlet and outlet tee or baffle condition, structural integrity, liquid IeveLs
as related.to outlet inven, evidence of leakage, etc.):
GrPaGa trap is nnf present-
7
Page 8 of I I
t,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 391 Main Street
Co ui , ass.
Owner: Carey & Grover
Date of Inspection: 1.2/2 9/01
TIGHT or HOLDING TANK (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:-'
Material of construction:concrete tlgmetal 414. fiberglass &y polyethylene4Z&other(explain):
Dimensions.
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: _4),4 Alarm in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
' t p
Tight or holding tanks are nor present.
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
r 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.):
nictrihntinn hax has two laterals.No evidence of solids
dem-p of leakage- into or out of box
PUMP CHAMBERVwe-(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):1G;2
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present
r
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 '191 M;�'i n c+ roo+
Cnttli t , Mass.
Owner: -Car ay R r,r��7er
Date of Inspection: 1 1)914g 1
SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required)
2-10 _
of 11 stone.
If SAS not located explain why:
Located; See page 10
Type ' �
leaching pits, number:_
leaching chambers, number:
leaching galleries,number: 0
leaching trenches,number, length:
,17 leaching fields,number,dimensions:
Eoverflow cesspool, number: O —, �-
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.):
Loamy sanr1 to fine sari mr) gii gnG— of by a.zau ic-
Or pondirLg Both of thg I aachi n- pits are 64-�—��z�rrTttiffle.
Vegetation is normal .
CZSSPOOLS4,)A�(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 0
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 or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.):
Cesspools arp,
PRIVYW&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.):
9
Page 10 of I I „
s �
OFFICIA.L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 391 Main Street
Cotuit.,Mass .
Owner. Carey & Grover
Date of Inspectioo: 12/29/01
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.
O
N
M
E� o
,tz
Q
3
10
Page 1 1 of 1 1 e "'
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 391 Main Street
COtultFinaSG _ -
Owner: Carey & Grover
Date of Inspection: 12 2 9.1
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water .t feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obta' ed esi lans on record - If checked,date of design plan reviewed:
bserved site(abutting rope observation hole within 150 feet of SAS)
_ ecked with local Board of Health-explain:
_IZChecked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USed t;ahrety Mi 11oar . 12/1619'4 Ground water ahnvA camelgVg�
USGS Ohservatinn we1�1 data Tttn® 1992
USGS Annual ranges of grn„ncl t,Jat®r. g:_ggg_1Pa-t e#2
TupofGround
Leaching
Pit -�
L� eet ,
Groundwater:9 t=eet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
N
I. Therefore, the vertical separation distance between the bottom
• of the leaching pit and the adjusted groundwater table is l'
feet.
11 •
`a'rinTr.-nTe+�.T- rnr mr•ntsn nrl+nr.nmmr.7r+`nn�IT.RRnm rte•rAler TsllnvIrT .TT•'+•'^,r+-+r-.... r...'
TOWN OF Barnstable WARD OF HEALTH �
SUIISHFACR 9NAGF DISPOSAL SYSTEM INSUCTION FORM - PART D .- CERTIFICATION
•••T1�T".•::.—T.11I.^�1T.ttT.TI•A.1TI T•IT.TTTTIRTT'r!.•1 ri!T1."I�IR1R-T�R.tA�Rl�1.f�'R'1�11 mnn ..��rr,�_�. ._. J
-TYPE OR PRINT CIX ARLY-
PROPERTY INSPECTED
STREET ADDRES$ 1391 Main Street Cotuit,Mass. ► '
ASSESSORS MAP, DLOCK AND PARCEL 4
OWNER' s NAME.Carey & Grbver
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph .P. Macomber Jr.
COMPANY NAME Joseph P. Macomber & Svn Inc
COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632
St'rvvt Town or City 3tat• LIP.
COMPANY TELEPHONE (508 ) 775 - 3338 FAX (508 � 790 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the inrormation reported is true , accurate , and
omplete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Chec1c 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 16 - 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED* \
The inspection which I have con lrcted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 30.3 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature
�elDate o'
ecopy of this rt.ification must be provided to the OWNER, the BUYER
On
where applicable ) and the 130ARD OF HEALTII.
* If the inspection FAILED, the owner or" operator shall u pgrade ' the system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 ChIR 16 . 305 .
partd .doc
TOWN OF BARNSTABLE
LOC�►TION V _ � �§ _ s� SEWAGE 9k
..
VILLAGE C,0+12 d — �.�ASSESSOR'S�MAP&LOT
INSTALLER'S NAME&PHONE NO. 3� 'fib
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) S - 1 V* (size) - k'
.NO.OF BEDROOMS e
BUILDER OR OWNER
PERM ITDATE: - COMPLIANCE .DATE:- 11/1
'
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
y `�* `
w` `
� , r a r
�. �.� �"
,r?"' . .
a,
,�, .�
�,
t� � �..
_�i .,•
�. t�,.
��k:
�+, ".
p
` 4
� ,�,_ �'
� ,
t � 4� _.•4 n� t...
�f '' Y
�! /
e .�.. /,_
No. ' (tom •" Fee
�j
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0(pphration for ]Die;pogal *p5tem Construction Permit
Application for a Permit to Construct Repair Fupgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 13011 119Af tu 5 -- Owner's Name,Address and Tel.No.
Assessor's Map/Parcel O
Installer's Name,Address,and Tel.No. lc3 Designer's Name,Address and Tel.No.
Ja m-P# �zgi
Dos
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 y�T Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
k� t
Nature of Repairs or Alterations(Answer when applicable) ��� � '� lY�T /a2 44M4
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 -the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Boar th.
Signed Date �v
Application Approved by Date
Application Disapproved for theqollowiQ reasons
Permit No. Date Issued
I_
No. I :,. ` Fee G7
r � THE COMMONWEALTH OF Entered in computer:uteri
4r "�••,�� p Yes
f
PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLES MASSACHUSETTS.
- uo
Z[pplicationf
por kv6pval �, Le, Construction Permit
Application for a Permit to Construct epair`�U,.grade( )Aban ( ) ❑Complete System El Individual Components
Location Address or Lot No. 1391 1;�,Aflk,) Owner's Name,Address and Tel.No.
Assessor's Map/Parcel D t Q p 6, a
Installer's Name,Address,and Tel.No. C� Designer's Name,Address and Tel.No.
J0f9
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
t
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
Na of Repairs or Alterations(Answer when applicable) , '
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 f the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this-
oard5 95mth. , ,
Signed ;: Date
Application Approved by Date 7
Application Disapproved for theYollowiQ,reasons `
r
Permit No. - Date Issued
————————————=,\———————————————, --—-————————
i THE COMMONWEALTH OF MASSACHUSETTS'
BARNSTABLE, MASSACHUSETTS:. J
Certificate of Compliance ,
THIS IS TO CERTIFY that the'On-site Sewage Disposal System Constructed( )Repaired><Upgraded( )
Abandoned( )=by C oL/ - 'D,(, ,,n- ,2 /
at _oWA, A.Z51 ' 49�'C/ �'r has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer r F I J
The issuance of this p:`�' t slia}n� ,6ZI8 m4rued as a guarantee that the y§ermn ill function as designed.
Date / �� Inspector i"i�� L�'�/T i E•
---------------------------------------
No. _ Fee/00 _
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
�Dizpoat *p!5tem Congtruction Permit
Permission is hereby granted to Construct(1'>C)Repair( )Upgrade( )Abandon( )
System located at /, / ��/ SjT ,�(,�Z 7--
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: _/n - q Approved by .
� o
r
�ow
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a TOLERANCES
ro�so NO DATE 8Y
ry
osWool n wwono
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TOLERANCES REVISION'S
txce.T As Mdtcd NO DATE BY 5r.
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.3
puw�i r tC w. p MAt! ' � � MMAL
_ 4... cmemeD �T Y OAt! wM10 N0
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Ref CERT. No. 14 323. • . '� � {
CFRT No. 28564 r a-
00,
• �: .,,�b ��r_ias ao f�w,�• . •�NSJ•• �cs' ae•�i►_ ':,�
Dunning. �Sf?ed!'r ,,_ '�w = ri.:•
r: �, LOT C.
d3q ' �j
7_
7
TOWN OF BARNSTABLE
LOCATION I a %`� � SEWAGE # F
VILLAGE ("0T3.1 ASSESSOR'S MAP &LOT� �
INSTALLER'S NAME&PHONE NO. E_C 6 ' —3 0 9
1
j SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) S tAnQ'I; (size)
NO.OP BEDROOMS
BUrLDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
yPrivate 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
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LOCATION SEWAGE P ROOT NO.
VILLAGE
INSTA L,1 R'S NAME & AD RESS
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ,
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LOCATION SEWAGE # --
VII.LAGE 4 eo ASSESSOR'S MAP & LO f
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /903 �' a
LEACHING FACILITY: (type),At'41 �� � / (size)
NO.OF BEDROOMS
d /e
BUILDER OR OWNER wt�
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 ac ' Facility(If any tlan sexist
within 300 f t e g ) Feet
Furnished b %
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2-19 G 2- Z8'
3-31 3- 1a�6`�
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEAL H
��19..........OF....
ApplirFation for Bigivii al Works Tong rurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
.._.... . .......... . . ,!? 7-••-••--•....... ........•-•• ._....... ...---•••..... --.............--------------..........._.....
lion- ddress or Lot No.
} , .: -- � '----- �a. el. "....... .................................................
w •---•---....:...
O z ...................Address
� ------....._
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (
Other—T e of Building No. of persons............................ Showers — Cafeteria
04 Other fixtures ............................. .............................................................
WDesign 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
ODescription of Soil ----------------- ••-•-------------........-•------.-••••.......................
x
.r .
x •••-------------------------------------------------•-•---------------------------•----------------•- -•----•---•--•----.... - --------- --
Lo
r, Nature of Repairs or Alterations—Answer when applicable_._.._/_.',1L1�._-._..._..: .' 1. __________________________
--------•---------------------------------------•--•--------------------------------.....---.......---------•-------------------------------------------------------------------------..._••-••-••-_--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T�'_ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issue by t e boa d of health.
p[
Signed _ . .....�..---• - --- -- .4__.....-- •--•---••...............�._
Date
Application Approved By---- -. .. .....��-� ....................................
Date
Application Disapproved for the following reasons:...............:...............................................................................................
_
.........................................................:...............................................................................................................................................
Date
PermitNo......................................................... Issued_...........................
rY .r
8 z 2 Y Fine....' .?.r
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�.I '. 'a.... ....OF......
,a.. .........................
Appliraation for Disposal Works Tomitrurtion 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( n Individual Sewage Disposal
System at
.........t'.::'° !._..... fr f. �'�.�s... f ............... ............ r;....._......... ........................... _ .............................
_Lopation-�.ddress M. or Lot No.
.... '1 ...�_.g./---- .;' .......-•------•---......--•---•............................
}^l lr Omer ' i 1. Address
✓ fri'�7 �!--' d
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
a Other fixtures .------------------------
d - ----------------------------------------------------- -------------------------------•-----------
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 ( )
�-' 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...;....................
W -.........i -- .;............- ....� ........................................................................................
O Description of Soil....................- ... . j'... � . --------------------------.
x
c.,
w ------------------------------------------------------------------------------------------•-------------------------------------------------------------------------•-----;...-•---...........-•••-•-•--
UNature of Repairs or Alterations—Answer when applicable.--____--___ f ........................ ............................................
----------------------------•--.....--------------------•----------•----•--•------------...----•--------••---------------------------------------------------------------...------------•••-••••--•.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued,by the board of health
Signed 'i�ssG
r�-' Date--•--......---
• Application Approved BY----•- ---� �....- '- ..................-''-- -•---.....--•-•----•-----.... -Date
Application Disapproved for the following reasons--------------------------------------------------------•-----------------------•--------._...-•-•--......._..._
--------------------•--------•---•-----------•---.....---.......-----•---•-------.....................----------....-------•---•---------•--------.._.._
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1
f ,�' s .., ..OF..... J:`......... ".. ^' `.:............................
Tntif irFatr of TutttpliFattrr
THIS IS T6 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �.
Installer
•-----... .•-, ...................... =
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. -Z= + - -------- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............................................S--.� `- `�'------ Inspector__............• . --- . ..................................................
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD OF HEALTH
r
_ OF Ie
No... FEE.....:
Permission is hereby granted..--------` !...----- - •- �'•-- --�,._•�---•--- �f---.�----...-•=-- ,;. �.:�_._.:°....,,.,,..
to Construct ( or Repair (j Lean Indio dual Sewage�Disposal,•System
at No.........
.... ..s.:_... 1 IT.:,.........__
Street
as shown on the application for Disposal Works Construction Permit No............-....4....... Dated..........................................
DATE.......................�-='�-��-��----
....................... B d of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS