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Commonwealth of Massachusetts
4— Title 5 Official Inspection Form
.i
Subsurface Sewage Disposal System-Eorfn=-fd crt
Voluntary Assessments
259 Mariner Circle Assesso s ma 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is required for every Cotuit MA 02635 May 2, 2015
�
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
� � r
on the computer, I
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr, IRS
use the return Name of Inspector
key.
Eco-Tech Rapid Response
Company Name
155 George Ryder Road South
Company Address
Chatham MA 02633
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority'
May 2, 2015
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system 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.
****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 pert rm in the fulu,re under
the same or different conditions of use.
15ins•3113 Title 5 Official Inspection Form:Subsurface sewage oisposal System•Page 1 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is required for every Cotuit MA 02635 May 2, 2015
page. City/town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
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.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
15ins•3/13 Title 5 Vidal Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 May 2, 2015
required for every —y
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired,
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N FIND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
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
15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owners Name
information is required for every Cotuit MA 02635 May 2, 2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, If any)
determines that the system is functioning In a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool .
❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less
than %day flow
t5ms-3/13 T81e 5 Official Inspection Form:Subsurface Sewape Disposal System•Page 4 of 17
Commonwealth of Massachusetts
G Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 259 Mariner Circle Assessor's map 24 Parcel 148
Property.Address
Barry P. Mirakian
Owner Owner's Name
information is required for every Cotuit MA 02635 May 2, 2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® 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.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El El Area
system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is required for every Cotuit MA 02635 May 2, 2015
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
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?
® ❑ 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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3/13 Title 5 Official Insp
ection Farm:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 May 2, 2015
required for every —y
page. CityrFown State Zip Code Date of Inspection
D. System Information
Description:
A system sized for 3 bedrooms was installed by Spero Theoharidis in 1981.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)): 26 gpd
Detail:
2013: 11,000 gallons 2014: 8,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: .
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
15ins-3113 Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is required for every Cotuit MA 02635 May 2, 2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
4
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 Ma y 2 2015
required for every _ ,
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 33+ years. Certificate of Compliance for new system was issued 6/25/81 (Permit*80-341 at
Health Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank (locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.5 x 5 x 6-1000 gallon
Sludge depth: 6 in
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w °`F 259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 May 2, 2015
required for every —
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28 in
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping is not required at this time. Maintenance pumping is recommended within 2 years and
every 2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and
functioning as intended. No evidence of leakage in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
A
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 May 2, 2015
required for every Y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
TI Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a, 259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 May 2, 2015
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at 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 appears structurally sound with no evidence of leakage in or out
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 May 2 2015
required for every Y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
El leaching trenches number, length:
❑ Teaching fields number, dimensions:
El overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. A hole was dug into leaching pit stone and no effluent contact staining was observed in the
stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the
peastone layer.
Cesspools (cesspool must be pumped as art of inspection) (locate on site plan):
P ( P P P 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 ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
I
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 May 2, 2015
required for every
page. City(rown State Zip Code Date of Inspection -
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.;:
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)::
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
i
Commonwealth of Massachusetts
--_- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is y Cotuit MA 02635 May 2 2015
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
drawing attached separately
MARINER CIRCLE
E
NOT ? W �(/r -- - //r���(/��\a-
J , .,, L`_s OVA T§O V v
TO o 0
SCALE Q —OF SEPTIC COMPONENTS
3 —DISTANCES IN DECIMAL FEET
a A 8
1 25 44
2 31 48
EXISTING 3 38 54
DWELLING
0 259
A B
THIS SKETCH IS
1 BEST VIEWED IN •
COLOR FORMAT
1000 GALLON
SEPTIC TANK
Q DISTRIBUTION BOX
LEACH 508 364-0894
PIT
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 May 2, 2015
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed. 7/10/1980
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database -explain:
Town of Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows bottom of system to be 4 feet above the
bottom of a witnessed test pit in which no groundwater was encountered. Town of Barnstable GIS
Department records indicate that the property is over 15 feet above groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page. .
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°( 259 Mariner Circle Assessor's map 24 Parcel 148
Property Address
Barry P. Mirakian
Owner Owner's Name
information is Cotuit MA 02635 May 2 2015
required for every Y
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
GEOHYDROLOGICAL PROFILE
- NOT TO SCALE
a t. ,
2
- Q
o,
PRECAST G
O
a LEACH W
PIT
2
s 0
BOTTOM OF
LEACHING N
PEA DESIGN
LEACHING.IS PLAN
ABOVE HIGH
GROUNDWATER
r-
v
NO
GROUNDWATER
ENCOUNTERED
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
: D,y/lVe)
Z9 T-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System-Form-Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for /?fit 9zces f 2
every page. CitylTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your
cursor-do not Name of Inspector
use the return
key.
Company Name
Company Address
'�1d0 Cityrrown State Zip Code
'7 6`.2-vg 5/ y37
Telephone Number License Number
B. Certification
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:
Rp
(Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority # =3
�
Inspector's Sign ure Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system-or
has a design flow of 10,000 gpd or greater,the.inspector and the system owner hall submit the—
report to the appropriate regional office of the DEP.The original should be sent)o the system o(ivner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
tIinsp.doc•11&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
1
5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w r 2 6 7 4N-riw� yy�
Property Address nn
1.�m�zc
Owner Owner's Name _
information is
required for
every page. City[Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined(Y, N, ND)in the❑for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass'inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
t5insp.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 15
ti
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owners Name
information is
required for Q,24'3s' 02
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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:
C) Further Evaluation is Required by the Board of Health: .
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless:Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41M 2 ✓
Property Address
Owner Owner's Name
information is _�o � 35— �2
required for c�cy�u
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ Ed Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ U---. 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
�/ Liquid depth in cesspool is less than 6° below invert or available volume is less
than'/day flow
❑ - Required pumping more than 4 times in the last year NOT due to clogged or .
obstructed pipe(s). Number of times pumped:
❑ E?,-- Any portion of the SAS, cesspool or privy is below high ground water elevation.
ElAny portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
E] ❑/ Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ 0""_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ p The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ R 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.
For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑
',the system is w in 400 feet of a surface drinking water supply
N' s
El El the r, rn is within 200 feet of a tributary to a surface drinking water supply
0 ❑ th�'sy�tm is located in a nitrogen sensitive area(Interim Wellhead Protection
area—I I?A)or a mapped Zone II of a public water supply well
If you have answ ed"yes"to any question in Section E the system is considered a significant threat,
or answered"ye _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 CM 15.304.The system owner should contact the appropriate
regional office of the Department.
t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owners Name
information is9�Cti�
required for
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
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
❑ 0— Were any of the system components pumped out in the previous two weeks?
0---- ❑ 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)
Ek ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
[� ❑ Were all system components, excluding the SAS, located on site?
❑�'❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑/ ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
L� ❑ Existing information. For example,a plan at the Board of Health.
❑ ❑� Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner's Name ,
information is
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual): °Z
.ec� o►� .�-eP 3 o ff �c �P Cv�.�3/?�O 13�3 3
DEVON 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 P—No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 2—No
Laundry system inspected? ❑ Yes ®- No
Seasonal use? ❑ Yes Q- No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes [-No
Last date of occupancy: Dale
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203): Gallons per day(gpd)
Basis of design flow(seats/perso /sq.ft., et .
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank prese ❑ Yes ❑ No
Non-sanitarywaste dischar to the Title 5 s m? Yes No
9� y ❑ ❑
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r< Cg
Property Address n
�Y
Owner Owner's Name
information is
required for /!�d'ke• (9oZ(3S`� 02 —��/—
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes Ej--No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ 'Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes 93-TVo
t5insp.doc•08106 Title 5 Official inspsdon Fond:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w �Z S Q i i�Y�Ni►*�Z ��
Property Address n
11�
Owner Owner's Name
information is /mac G�ZlP35' o2
required for
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 3 c�� `'�"i' ayw�P'e,. t
Material of construction:
❑cast iron 40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes.Boo
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
Sludge depth: vz°
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
511sp.10c•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
2 5 9 C .e
Property Address
Owner Owner's Name
information is
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,
evidence of
leakage, etc.):
Grease Trap(locate on site plan): .
Depth belo grade: ^n
.,/� feet
Material of con caction:
❑concre metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bo m of scam to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pu ping�egommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as rel ted to outlet invert;evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction-
0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
t5insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
02 s1
Property Address
Owner Owner's Name
information is � 3 f
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) i
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No ,
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes Q�No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: 1 ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp.doc-08/06 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
oZ
Property Address
Owner Owner's Name
information is
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
�L �
i
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type.
}/ leaching pits number: / fP >e 8
El leaching chambers number:
leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: '�'�'`°�
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
t5insp.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5�
Property Address
Owner Owner's Name
information is A"-Ice-
required for
A"-Ice-
every page. City/Town State Zip Code Date of Inspection
D- System Information (cont.) �
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert.
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):.
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
-- W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for Z�C3 'uC 35 -.2-
every page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
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.
L01yA ION �?5y SEWAGE IT N0. \
f'� S�/Y/l�l?iNF_IZ ri E'GLF g�
VILLAGE
L-O"TUl7
INSTAL ER'S NAME A AD"RESS
RUILDItR ,OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
-ri7
H E.-
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address n
Owner Owner's Name
information is
required for
every page. Cityrfown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water -
❑ Check cellar
❑ Shallow wells
Estimated depth to ground water: feet �9
Please indicate all methods used to determine the high.ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accesse USGS.database�-1plain:
You must describe how you established the high ground water elevation:
y
�� . Y
i � ?
t5insp.doc•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Town of Barnstable
Regulatory Services
$ BARNSrABLK ; Thomas F. Geiler, Director
y$ 1Mass . g .
alFp3.�p Public Health .Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
not does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
NCY F
THE COMMONWEALTH OF MASSACHUSETTS ~
` BOAR® OF HEALTH
VW ...................oF.., 3 ......------------..........-----.--..----.------
ApplirFation for Dispnstal Works Tonotrnrtion ramit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
Sys-em.at ,A ZX4V
,-• -, --... � ................
Locatio Ad �� or Lot No.
a ... .
caner .A_.r s
Installer Address
dType of Building Size Loty .....Sq. feet
U Dwelling=No. of Bedrooms........ .....o ._.................__.._.Expansion ttic ( ) Garbage Grinder ( )
Other—Type of Building ------------------ ------- No. of persons......./_�A._....._...... Showers ( ) — Cafeteria ( )
Q' Other fixtures ............
Design Flow............�`....................gallons per person per day. Total daily flow.._.....-.9_4-0...................gallons.
Septic Tank—Liquid'capacity/O."..gallons Length..f!9.�... Width..�t!.lv._ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length................._. Total leaching area....................sq. ft.
Seepage Pit No--------/.......... Diameter...... Depth below inlet-•- -,j.....
.-- Total leaching area..................sq. ft.
Z Other Distribution box (/) Dosing tank ( )
`-' Percolation Test Results Performed by...... -------- -. Date.....
,aa Test Pit No. 1................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........................
a .......... -- -•----•-----------••-•---••••-•-•---•-•-•••••............................••--•••............•---------•-••------......._...._..---••-.•--••-
0 Description of Soil..-- �D a.: .........-••----•••••---•••----•••--------•••-----•------•-•-•••-•-•-•--•.............•--•-....................--......
x .......... - -------
UNature of Repairs or Alterations—Answer when applicable.-..............................................................................................
--•--------------------------------------------------------
•--------
•------
•----------------------------------
------------------
----------------------- .......
••-•-•-•---.....--------..----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i I':.r� 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by th and o health.
Signed: _.. ..1�....
Application Approved B ........ ....._.�.P/a-ate ....
PP PP Y
Date
Application Disapproved for the following reasons:................................................................................................................
-•-•----•-•------------------•-------•--....---....------------------------•-----•--••-----•-•••••----_..._
Date
PermitNo.......................................................- Issued-.......................................................
Date
. y
Fas. . ...........
THE COMMONWEALTH OF MASSACHUSETTS '* ~
BOARD OF HEALTH
Appliratilan fnr`"'Disposal 19orks Tonstrurtiun Prrutit
Application is hereby made for a Permit to Construct (>{ ) or Repair ( ) an Individual Sewage Disposal
System.at
// Locatiori-Addiesi or Lot No. ---
............................. . ----••--••-----f' ........................= = .....................
T/ er !Address
Installer Address
d Type,of Building Size Lot.=-------------------------Sq. feet
V Dwelling—No. of Bedrooms................................_..........Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ....... No, of persons........./................ Showers ( ) — Cafeteria ( )
dOther fixtures ........................J....................................................-.......... .............................................................
W Design Flow................`- ...................gallons per person per day. Total daily flow............t.._'-?:. "?...................gallons.
WSeptic Tank—Liquid capacity,r .gallons Length_ .'�2..... Width. /.f_"'.. Diameter.............._ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........!_.......... Diameter....... Depth below inlet._.V.7..`..... Total leaching area..................sq. ft.
Z Other Distribution box (/ ) Dosing tank ( )
'-' Percolation Test Results Performed by.._.., �ti+��?' ' "{-.. f'r: 4?c3'� %'L_.__._._... Date....t-"I"
a .._....-•---•-•-•----
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.__...j.-.........:,__.
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x ---------=--------------------------------------------------------------------------•-......._•-----.........................................................
D Description of Soil....K• .......
U -...........................•-••-1^-.�--` •-----' 1�..�; .�c..._......---......----•-•-•-------------.......---•-----------------------•--....................-----•.--•-----....._
W 7 c/- /1/-,/ /l(.,u�/- )r,tr-( .
..-•------------------------------------------•--------------------•-------=-----------------------------------------•-----------•-------------------------•-------•------------------------------•-•--
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
•.........................................................--.........................:.................................................................................................................
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 been issued by the board of health
......_._
..
Signed
ei ... .....
Date
ApplicationApproved By............. .................................................-........................... ... ..`.
Date
Application Disapproved for the following. reasons:.•-•---...••---_:'°....-------•----•-------•----•-----......................................................
•-------•••---------------------••-••-----•--------...........------......-•••-•-•--•----•--_..•••----_...............-•-•------•-----••------•----•-•------............................................
Date
PermitNo........................................................ Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS /� % dra+-
BOARD OF HEALTH
(/�.................OF..... /r�...l.."t!-....................._....• .•..... ✓�'�"I
(Inrtifiratr of Toutpltnnrr 11-A
THIS IS TO-CERTIFY That.the Individual Sewage Disposal System constructed ( ) or Repaired;:(. ) 611'0fl
by --------•.-•••..............•-----•--•-----•----•.......................
.............. Installer
..... / f•;
has been installed in accordance with the provisions of of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N .... _____. _.�,�--------------- dated__. '._zo."40r_-d......._._......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................... ... Inspector_. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH'A"q/r, /o /Y/I XF
WFEE.3 ............
,,
Disposal Works Tnntrnrtion prntit ,
Permission is hereby granted__._. f l ..... ............._... ,../�tl ...i..-��`"�
to Construct (4) or Repair ( ) an -Individual Sewage Disposal System
at No
: /. - J �f'
'�`:.-------• .� �----- .....,-•--•-•.................�--•-----....----`Street----•^-..�_......_....--•----••--•--._._.........----....._..................
r u.�w - _ w, Gr
as shown on the application for Disposal Works Construction PSpnji N .. :... ... Dated... y-/0'- ...............
G'
Board of Health
DATE------. ..... ....
---•----------------_-........
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
TOWN OF BARNSTABLE
LOCATION .2 5-9 SEWAGE#
VILLAGE C^p ASSESSOR'S MAP&PARCEL ,02Vq
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY D
LEACHING FACILITY:(type) 1-0a size) 0-,�
NO.OF BEDROOMS o2-
OWNER
42tr�-
PERMITDATE: COMPLIANCE DATE: —L-2
fl
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 N- D mA
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N
N
N 69
a
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IT
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0
14 K E7 �
,5q
f'^r
f
i
i
W
F.FL. ELEV.: 56xo
FINISH GRADE _ � FINISH GRADE FINISH GRADE=--
TOP OF FOUND, OVER TANK _ � OVER PIT _1
ELEV.
4" T 4v CHIMNLY *LOCK
C.I. BACKFILL
DWELLINB . 4 V•C• 3" PEAS TONE
C —_
o
v ° O O O o p
CELLAR F °LOOR I�c-� GALLON ' '!_yo_.._� s o'3� O O 0 O O e � 3/4" 70 1-I/2
ELE1I = REINFORCED GONG. v !'j ° O (J O 0 s ,� r CRUSHED STONE
O O
0 O o
\ ° 0 0 O Q. C� O d
• 9 • • • � „ �• DIST. BOX v ,o P
. /
O O O O
SEPTIC TANK r- (TO BE LEVEL p a (q O O O. V ° BOTTOM OF PIT
AND STABLE ) /` ° 0 O O o 4 �; ELE'L = 4 }C4
SYSTEM PROFILE
( NOT TO SCALE)
LEACHING PIT
DESIGN CRITERIA
/000!
Al,1M$ER OF BEDROOMS =
,Gar s'4 r,
GALLONS PFR 0,4Y
ozx
GARBAGE GRINDER = /✓�U� t`I / .-'"""' - t r
TOTAL DAILY FLOW =--___._tea G P_ �
- --
LEACHINOAREA PROVIDED il: l r'•� ��"r ' �, y ���
?'a 7744. s e G 7p' a -E 4
SOILS LOG
0" ELEV. sl Y.�
� l�O .do "= `c•
! PROPOSED SEWAGE
14+4° 1 _1 DISPOSAL SYS T EM
�'�'�• '`'� '���"��
INSPECTED BY PROPOSED DWELLING_
; :Z4a2y A.qi i/ .Os/
DATE MASS.
PERCOLATION RATE MIN-/INCH —`�-
---Z.---- SCALE' AS NOTED DATE
l ISLE// DAY �/SL . �4Tl1/y OWNED BY:
S • .CaTSNDIL�N d'l/ 7Z/!3E l67 5N667'Z �"N OF MA,p�C GE1�AR AO'?2Es REAL Ty TR.rJST
3• E'F ZGN �`� 9G24gZE.b+T F�i .>� DP Jr_
o NOR►1 A `ne^ 5C- �(!�•tp a rti i{�:
Q• No 7- /.Y FLDo= ALA IN GROSS AN _
-�� "/ST 75 01 NORMAd GROSSMAN PE, RL.S.
6 aPi� F�cv, ¢ 226 HOLLY POINT ROAD
;-� z?- '�' �~'�-`•T r SSIpNp� ��G CENTERVILLE, MASS.