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Home My WebLink About1715 MAIN STREET (COTUIT) - Health 1715 Main Street;(Cotuit) Cotuit P ' 016 003 i i No. rxv/ �` Co ✓ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[pprication for Misposal *pstem Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components r Location Address or Lot No. j"f/3 A r 11 Owners ame,Address,and Tel.No. Co`�v� T Assessor's Map/Parcel (, Be_ th eAJ 5 Insta s Name.Add ss, d Tel.N . Sa Designer's Name,Address,and Tel No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) C J Cal 1 ,Lj DIP V: 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 ronme tal Code a not to place the system in operation until a Certificate of Compliance has been issued by this oa of Heal Signe Date S /� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ,�pj/ `�--! (9 `� Date Issued No. Y Fee ,C5o THE COMMONWEALTH OF MASSACHUSETTS .... Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIPPlication for Misposal �&Pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /74. /#I A'/� 1 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 13 Y( r-eii s Installer's N/ ?Addr ss,and Tel.NJ. �., j-,-6 S� Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil � f Nature of Repairs or Alterations(Answer when applicable) N `-j i Date last inspected: Agreement: The undersigned agrees to ensure tie construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 o vironmental Code a d'not to place the system in operation until a Certificate of Compliance has been issued b�6a nd of Healt Date / Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that th On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded) Abandoned( )by � ye- 1 A at ) T� -� t�o ,�, ^�" has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NQ—_/AV,�k— dated Installer___7 L�� -f � ,e3 so Designer uJq r #bedrooms Approved design flow gpd The issuance of this permit shall not be constru d as a guarantee that the system will fu ctiW�;4 signed. Date (A t �rk Inspector`-,... C No. J (D� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC-HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade,(�) / Abandon( ) System located at � I and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mu t be completed w_thin three years of the date of this permit. Date o� r / Approved by II L4 TOWN OF BARNSTABLE LOCATION SEWAGE# �hZS of - �✓ 7 VILLAGE ASSESSOR'S MAP&PARCEL6/6 QjY3 INSTALLER'S NAME&PHONE NO. �/� SEPTIC TANK CAPACITY /,ADD Cql✓ /D LEACHING FACILITY:(type) L /}/D (size) ,�BD 15!� NO.OF BEDROOMS OWNER ]Z�nu'+-Tz> WM u c- PERMIT DATE: I w Z 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 Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 7,3 o 0 G as.(10 E 7T(0 E G 61 ,(0 ®. TOWN OF BARNSTABLE LOCA iiUN SEWAGE # aOO2-Y/.-7 yu,L1,,GE CO r7/ ASSESSOR'S MAP & L010 INSTALLER'S NAME&PHONE NO. l /coo SEPTIC TANK CAPACITY fi—OD LEACHING FACILITY: (type) C "/49 (size) S-00 �l NO.OF BEDROOMS � M BTJILDER OR OWNER s ///� PERMTTDATE: Iq 6 2 COMPLIANCE DATE: 1 Lo ; 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 Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by f t �e Tc� I 3, S O S \3, o 4 44 o Q't O� I � 7 I -ed ( LO IRK t� _J t1's W_ No. Q 2k Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitation for Mizpoar 6potem Cow6tructtou Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. i Own e, dre and Tel.No. Assessor's Map/Parcel �/� ,./�® pif Installer's N A s d e1. o.�✓ Designer's Name,Address and Tel.No. T06 S1Y0C4'<f1 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) Date last inspected: Agreement: The undersigned agree sure on cti nd maintenan a of the afore described on-site sewage disposal system in accordance with the p visions of Title o t n it nm 1 C and not to place the system in operation until a Certifi- cate of Compliance ha been i is o f 1 1 Sig Date M Application Approved by ' ® Date Application Disapproved for the following reaso s Permit No. Date Issued �A ------------------------------ -- ---— k No. F ,,, Fee • THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y_�/ ' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,,MASSACHUSETTS _ 01ppfication for Mitpool *pgtem Construction Permit � r Application for a Permit to Construct( )Repair( )Upgrade( ),Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. I Own ame, ddre and Tel.No 7/,5 .� n �a Assessor's Map/Parcel •„�6269� \ Installer's N n dress.annd el.�ln)�ffols Designer's Name,Address and Tel.Igo. p/� D4VE s/w/cal Type of Building: f Dwelling No.of Bedrooms Lot Size t 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) _ Date last inspected: Agreement: The undersigned agrees to-ensuretfi on ;tiPnnd maintenan e of the afore described on-site sewage disposal system in accordance with the pr visions cf Title o )rnnm 1 C6 6 and not t place the system in operation until a Certifi- cate of Compliance-jjbeepisi d-b is o f dal .1 e q �h /! Date Application Approved by r�` / i .y7 /�" Date Application Disapproved for the followingreaso s Permit No. .� Date Issued y THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by �-� at ti has been constructed in accordance • with the provisions of Title 5 and the for Disposal System Construction Permit No. 200"1 17 dated Installer Designer The issuance of thiVperrrtt shall noi be construed as a guarantee that the system s rgned. Date 1111Z.103 Inspector �• J No.----gojn�2—_�/ ---------,----------- Fee � ' J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Miopool *pgtem Construction Permit 'Z_-11 Permission is hereby granted to C nstruct( )Repair( )Upgrade( )Abandon"(,• ). System located at qL5- a;it 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 followir_g local provisions or special conditions. Provided: Construction ust a completed within three years of the date of this pe i Date:_. l (Z Q Approved by �.� D2M TOWN OF BARNSTABLE LOCATION I7/� ��"yi'` 57 SEWAGE # 020o-2—�1 VILLAGE_ Cn ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO. e / (�oo SEPTIC TANK CAPA(=—, IJ 02 I/C7 LEACHING FACELrN: (type) (size) SRO *1�"/ NO.OF BEDROOMS Ste` yy� BUILDER OR OWNER PERMTTDATE: 6 2 COMPLIANCE DATE: 11 6 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (1f 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 i 1 l c t � �S %4 Ira I � � c" r• r No.----- - - D�c -- Fee--- -------------- BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion Ar Well CootructiodPrrmit Applic tion 's hereby made fo a pe t t Con truct ( Alter ( ), or Repair ( )an individual Well at: -- Location — Address Assessors Map and Parcel O ner Address �Gy Installer — Driller Address 7` Type of Building -' >�� Dwelling -— —--- ----------------------------- Other - Type of Building--------------------- No. of Persons------------------------------------- Type of Well --- -- Capacity------ —�� ! -------- Purpose of Well Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of H Ith Private W 11 rotection Regulation - The undersigned further agrees not to place the well in operation it e o i e has been issued by the Board of Health. Signe date Application Approved By v ------- date Application Disapproved for the following re ns:--------------- - - —-------- -- - ---—----- r ___ Issued-- / ----date-- — Permit No.- -- T- - date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS TO CERTIFY-That Individu 1 Well Constructed (Altered ( ), or Repaired ( ) ---------------bY- - -- - ------- --------- - -_ —_ --- L--------_-— .Installer uat 4-?4rY _SE _--- - -------- -- -- --- -- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. --------------------Dated--------- ------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------- --- -- Inspector---- --- -- ------------ P. No. & -- Fee- - - -; BOARD OF HEALTH TOWN OF BARNSTABLE F- 0(pplicationArVell Con5tructionPermit Applic tion 's hereby made fo a permit t Con truct ( , Alter ( ), or Repair ( )an individual Well at: 66 ALocation — Address Assessors Map and Parcel il? _ Owner Address --------------------- ------- ---- Installer — Driller Address Type of Building Dwelling--- —-— -- - ----------- jOther - Type of Building-------------------- No. of Persons-------- ------------_—__—____—_____ C Se"� Ca acit /S � -�--J �I TYPe of Well--— / --- - P Y---- - - -- �� ------- Purpose II of Well------� -- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private W 11 rotection Regulation-- The undersigned further agrees not to place the well in operation til 1 ti iE� f o i e has been issued by the Board of Health. Signe - d // * date Application Approved By 67 / = "! --- date Application Disapproved for the following rL/ns: =------ - ------______—__—_— ---------- — J;— --__----------- --- --------date Permit No. t-/ -" -- �� -- ------ �---- Issued �-�----fl,------- , date BOARD OF HEALTH j TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CER IFY, That the Individu 1 Well Constructed (Altered ( ), or Repaired ( ) � --- /—I�nstaller by----- -------------------------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------------------Dated--------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. !f DATE----------------- --- - — —-- Inspector----------------------------------------- - BOARD OF HEALTH �i TOWN OF BARNSTABLE 'G Well Cootructionpermit No. UV � (J Fee Permission is hereby granted - �'C`�� -- ---------- --to Construct (L- Alter ( ), or Repair ( ) an Individual ell t: No. ----/7/S__!l �i✓ .� O 61, ------- -------- ----------------------------- Street as shown on the application for a Well Construction Permit No.-� � d D�----- - Date --- -__-- (-�----T -- --- - - - - Di -oard of Health DATE -- — I � 9/27/01 GATE :---------- - PROPERTY AOOREss: 17_,1_5_Main_Street...... ---Got-u-i-t,44a-6-6n---------- 04-M, ---02635 On Iho obovo dale, I inspooled the oeptlo ayfle*M at the aboYo addre55 This 5y5llom conalala of (he (ollowing: 1 . 2-6 'X8 ' Block cesspools in series witha 2 'X10 ' leaching trench. RECEIVED asied on my In;pecllon, I oorilfy Iho following oondlllo a OCT o 9 2001 2. This is not a title five septic system. 3 . This is a sewage system TOWN OFBARNSTABLE 4 . The sewage system is in proper working order HEALTH DEPT. at the present time. 5. Pumped cesspool f.�at time of. inspection.No water intrusio Apresent.Both of t1�Qr1ATURE't./ cesspools are structurally sound. 0. The is dry. Compeny Jo, •4h_P � N• comb•r_6 $on , Inc , 6------------- _-C�nc �rrllle � Her_ 026�4-OOb6 Phone ;___, 508_775_ 73 )8------- TM15 CERTIFICATION 00C9 NOT COHSTITVTC A OVARANTY OR WARRANTY a � JOSEPH P, MACOMBER & SON, INC, T+nk�.0ii�pooll.lr+chll+ld� Pvmptd 4 Initillid Town 3twir Conn'900111 P.O. aox 66 CinlirYllli, HA 02637-0066 7M))J B 77$4412 AY y ,per �-\ COMMONWEALTH OF M.A.SSACHUSETTS 7 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: 1715 Main Street Cotuit,Mass, Owner's Name: Richard A & Dorot-hy R. Church Owner's Address:P_O_Rnx 1 87i Date of Inspection: 9/2710T Name of Inspector: (please print) J.P. Macomber Jr. Company Name:Joseph P. Macomber & Son Inc Mailing Address: P.O. Box 66 r,=nf-PYyi 1 1e Ma 42632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT 1 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: v Passes _ Conditionally Passes _ Needs Further Evaluation by the Local Approving Authoriry _ Fails Inspector's Signature: Date: The system inspector shall s mit 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 ""This report only describes conditions at the time of Inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1715 Main Street o ui , ass. Owner: Richard Dorothy C urc Date of Inspection: 9/27/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D System Passes: ibchave not f fo hich 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: Tha cPwary= cxrat-am is in nr-nn=r wnrki nth nrr9Pr at }ho r nQQGQ+- limo B. System Conditionally Passes: &d 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: ,A)J 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: A)d 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 Page 3 of I 1 ` OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1715 Main Street Cotu= ,Mass. Owner: Richard & Dorothy C urc Date of Inspection: 9 2 7 01 C. Further Evaluation is Required by the Board of Health: A16 Conditions exist which require ftuther evaluation by the Board of Health in order to determine if the system is failing to protect public healh, 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: AX Cesspool or privy.s within 50 feet of a surface water �1 Cesspool or privy :s 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: .26 The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or rributary 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. IGL� The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 46 The system has a septic tank and SAS and the SAS is less than lop feet butt,�O 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 litrogen 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: Tho GPwage system consists of. 2-6 ' X8 ' block cesspools wi-t;h a- V X1 0 ' l Panhi ng trench These are all in series. See page 10 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1715 Main Street C0tLit,MasC;_ Owner: Richard & pnrnthW rhnrnh Date of Inspection: cl/i 7/n 1 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No� _ ��///�ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ;/ Discharge or poneing 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 bo bove outlet invert due to an overloaded or clogged SAS or JJ cesspool _ � Required squid depth in cesspool is less than 6"below invert or available volume is less than ''A day flow pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped I. /Any portion of the SAS, cesspool or privy is below high ground water elevation. _d Any portion of cesspool or privy is within 100 feet of a surface water,supply or tributary to a surface �ater supply. 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. �y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with r:o 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 trust be attached to this forma (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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply tc large systems in addition to the criteria above) yes 1/the _ system is within 400 feet of a surface drinking water supply II-le system is within 200 feet of a tributary to a surface drinking water supply Wellhead Protection Area—IWPA or a mapped — _ the system is located n a nitrogen sensitive area(Interim ellhea ) pp 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 sgnif cant 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 1 , OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1715 Main Street o ue , ass. Owner: Richard oro y Church Date of Inspection: 9 27 01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No/ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks 1,; Has the system received normal flows in the previous two week period? — / ave 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 /A Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out ? Z— Were all system ccmponents,.e-eluding the SAS, located on site ? X.Ue Were th septic anholes uncovered,opened, and the interior of the tank inspected for the condition of the ffles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum ? _ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing informatio.i. For example, a plan at the Board of Health. Determined in the f•.eld(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1715 Main Street Cotui=,Mass. Owner: Richard & Dorothy Church Date of Inspection: 9/2 7/01 — FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 C.%4R 15.203 (for example: 110 gpd x#of bedrooms):L � Number of current residents: It Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system y s or no): [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use: (yes or no):_ Water meter readings, if availa':)le(last 2 years usage(gpd)): If well has net/been Sump pump(yes or no): 6l5 tested in the 2 months Last date of occupancy: '! %Ito) It should be done now. See pages 6A & 6B COMM ERCIALINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):1-4 Water meter readings, if available: Last date of occupancy/use: OTHER(describe): 41W GENERAL INFORMATION Pumping Records Source of information: A)C1 7- Was system pumped as part the inspection(yes or no): .y If yes, volume pumped: ' B®gallo -- How as quantity pumped determined? Reason for pumping: xx ye/g � TYPE OF SYSTEM iGA_Septic tank, distribution box; soil absorption system Single cesspool r � _. 5 Overflow cesspool WA .� �r ��2 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) ,fight tank 6p_Attach a copy of the DEP approval Other(describe): Ap roximate aye of all comg➢onerts, date i-n.stalled ( f known) n� s rce of information: ekl Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1715 Main Street Cotuit.Mass. Owner: Richard & Dorothy Church Date of Inspection: 9/2 7/01 BUILDING SEWER(locate on site plan) Orangeberg pipe from the to the two cesspools. Depth below grade: _ Seh. 40 4" PVC pipe from Materials of construction: cast iron 40 PVC L�other fexplain)f 14 Distance from private water supply well or suction line: �' 1 lD Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight -No evidenrp of 1Pakagp—System is v nted through the house vents. SEPTIC TANK locate or site plan) Depth below grade: A/A Material of construction: A/Aor.crete e4metal AIA fiberglass dA polyethylene &Aother(explain) If tank is metal list age;go Is age confirmed by a Certificate of Compliance (yes or no) (attach a copy of certificate) Dimensions: Sludge depth: �( Distance from top of sludge to bottom of outlet tee or baffle: 410 Scum thickness: Distance from top of scum to top of outlet tee or baffle: I)/) Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Pump the main cesspool annually_ Septic tank is not present_ GREASE TRAP?Z locate on.site plan) Depth below grade:/ Material of construction:4Qconcrete4)-14 metalAll fiberglassXkolyethylene ,0 other (explain): AM Dimensions: ,l/iQ Scum thickness:_10 Distance from top of scum to top of outlet tee or baffle: .41X Distance from bottom of scum to oottom of outlet tee or baffle:_ )X Date of last pumping: 40 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GrpasP trap is not nrpsent z z 7 i 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: 1715 Main Street Cotuit,Mass. Owner: gichard & Dorothy Church Date of Inspection: 9127/01 TIGHT or HOLDING TANK&,&(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: lof Material of construction: concrete-44 metal AJA"fiberglass dj&olyethyleneA/k other(explain): 1 Dimensions: Capacity: allons Design Flow: gallons/day f ' Alarm present (yes or no): Alarm level:_,L4 Alarm in working order(yes or no): .l�lP Date of last pumping:X Comments (condition of alarm and float switches, etc. Tight or holding tanks are no present. DISTRIBUTION BOX41 (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): Distribution box is not present. PUMP CHAMBEWw6(Iccate on site plan) Pumps in working order(yes cr no): CO Alarms in working order(yes or no):� ,-omments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump- chamber is not present 8 Page 9 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address. 1715 Main Street Cotuit,Mass. Owner: Richard & Dorothy Church Date of Inspection: 9/27/01 SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan,excavation not required) 2-6 ' X8 ' block cess pools and 1 -2 'X10 ' Leach trench in series. If SAS not located explain why: Located Type leaching pits, number: d 4,j) leaching chambers, number: a leaching galleries,number: leaching trenches,number, length: I mod' eaching fields, number, d:mensions: O overflow cesspool,numbe-: t ,Q umovative/alternative system Type/name of technology: ��/,�j►'' jDi�?j� I�� Comments (note condition of soil, signs of hydraulic failure, level o ponding, damp soil, condition of vegetation, etc.): Loamy sand to fine sand.No signs of hydraulic failure or rnn_di ng_Rc; 1 s are dry. Vegetation is normal Service covers Pumped cessp ols at time of inspection.No signs of water �i fO 4LT�cesspool must be pumped a�part of inspection)(locate on site plan) 0 Number and configuration: Depth—top of liquid to inlet Vert: Depth of solids layer: C Depth of scum laver: Dimensions of cesspools J Materials of construction: �1CltL°J$ lndicatlon of groundwater inflow(yes or no): 40 Comments(note condition of soi., signs of hydraulic failure, level of.ponding,condition of vegetation, etc.): Same- as above PRIVY/1� (locate on site plan) Materials of construction: Dimensions: dW Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present, 9 i i Page 10 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1715 Main Street Co ui:,Mass. Owner: Richard & Dorothy Church Date of Inspection: 9 27; 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. S L ! 17/5 �o G"f- _ �b 1-716 A ca '� 1.0 • ..*,Page 1 1 of 11 s s OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1715 Main Street Co ui ,'Mass. Owner: Richard & Dorothy C urch Date of Inspection: 9 27 FO1 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water / feet 1 Please indicate (check)all methods used to determine the high ground water elevation: ��brained from system design plans on record - if checked, date of design plan reviewed: l/ C,bserved site(abuttin proae ➢observation hole within 150 feet of SAS) he ee wtt ocal Board of Health-explain: 77 +ecked with local excavators, insta�11 ers-L(att ch documentation) _, /Accessed USGS database-explain: Je bPa4/) You must describe how you estaolished the high ground water elevation: Used;Gahrety & Miller Model Groundwater Contour elevation above sea level Used;USGS Observation well data For June 1992 Ysed.; )Sr' Survey- 92 0001 P1 atP#? Top of Ground ;eet Groundwater:7 Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. . 11 •nrnrn rt•ram-�T- mr•nmr.s-nn rnrr+.nt.1'+n�rrrmrnmnfrerwy ►w•�n�tu�+ '1'OwN OF Barnstable I10ARD OF HEALTH S01I,SURFACF SFwAGF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION T'1�T•"".—T.1If.�T.TT1�1f!111'If.'.TITT.RT1flTRT:r 51�11RR't 7AnR-TTT.�►�RTf7 �n J -TYPO ON PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRES$ 1715 Main Street Cotuit Mass. ASSESSORS MAP , BLOCK AND PARCEL # 016-003 OWNER' s NAME Richard & 'Dorothy Church PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & Sarn Inc COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Strout Town or City Stat- LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790- 1 578 CERTIFICATION STATEMENT q I certify that I have personally inspected the sewage disposaj 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 . Che-ck one - stem: yPASSED The inspection iihich I have conducted has not found any information which indicates that the system fails to adequately protect public he.a1Lh or Lhe environment as defined in 310 CMR 15 - 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 vcted has found that the system fails to Protect the j)ublic 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 ' 4 Inspector Signature Date ! `� C- IN6 _..� ... ne copy of this cer .if.ication must be p vided to the OWNER, the BUYER ( Where appliCable ) and the 130ARD OF HEAL1'll. * If the inspection FAILED, the owner or.."operator shall u d within one year of the date of the inspection , unless allowed ortrequiredm otherwise as provided in 3.10 CHR 16 . 305 , partd . doc 061Z-9CS-L19-dNOHdg-ML .9I IZD&L asaFovssm-Noisoa - �7`//J) S l i a S fI H D V s S V W '.L I n.L O_D 's df102io NoISff�I ISSWo �eo� _ - -� 121R?I.LS INIdNi Stet. d zalo•o ' — y t 3i -i t Y �� I. 1 FI� I � U � ct• 3 _ I. j1 N; n3{£ 't �� £ Z -.4 .,E ,�•n.8-��I ,^U`,5;0'�£ N - °; } III iIS' r p ll II r—i - t � z I — N _ — I � W_ f� --- IIII N 1 ,5 9, JU . � '' .__.. R- I,0-,b. n -b'_�9� -�318,�_4. ram._^%:i... '49•d ,IJ_ly__ — ..i___--.-..- _ — �y.'-�; - —___._) - Q - N• N 'N' n I S ..1._'£a ..�Je a-L T As I it <0> 16 FOE i 9 4I I� II . 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