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HomeMy WebLinkAbout0039 MASHPEE ROAD - Health _ 39 hlashpee Road, Cotuit _^I A=007 - 038 No. r Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppliLation for -MisposaY 6pstem Construction permit Application for a Permit to Construct( ) Repair Pc Upgrade( ) Abandon(k) ❑Complete System ❑Individual Components Location Address or Lot No. j P moo _ Owner's Name,Address,and Tel.No. 608 Assessor's Map/Parcel to� Q 3s- ����M` ` ► /��— . Installer's Name,Address,and Teo.No.,,6b$- Desi Ar'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 1 NatuVeofR. epairs or tera^ttiions(Answer when applicable) l�.' l 1 0( 1, r _ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental a an of to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. tgned Date 3e3 1 Application Approved by Date v1 Application Disapproved by -- Date for the following reasons Permit No. C�q> Date Issued S5 No. �! �!#r _r Fee THE COMMONWEALTH OF•'MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9pplication for Disposal *pstrm Construction 3pPrmit Application for a Permit to Construct( ) Repair(_N) Upgrade( ) Abandon(y) ❑Complete System ❑Individual Components Location Address or Lot No. �i'7QJ��p p f y Owner's Name,Address,and Tel.No. 6-08-cx_jF� I_""- Assessor's Map/Parcel f7 3 n �3 t �Rash� Installer's Name,Address,and Tel.No. ,9)g_;/ �.���� Desi er's Name,Address,and Tel.No. �P-k�lGtt:c. C'�onStfuc.�-1,c1•r,;�t.�x, r,�-5-i��c5�r2� i� Ftnr ., Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) a Other Fixtures Design Flow(min.required) �° gpd Design flow provided gpd Plan Date F Number of sheets Revision Date ti ~--_ Title #; J..^ Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) "y�j e��-� ; j qji 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�this tle 5 of the Environmental Cod an of to place the system in operation until a Certificate of Compliance has been issued by Board of Health. tied Date TC) f Application Approved by DateZ 2 /q— Application Disapproved by Date for the following reasons j Permit No. _Qh 454) Date Issued THE COMMONWEALTH OF MASSACHUSETTS C of l e_ BARNSTABLE,MASSACHUSETTS . d r I d it(i,c ; i d rr ;tL' certificate Of COMP[iance THIS IS TO CERTIFY,that the On-site Se ag2 Disposal system Constructed( ) Repaired()<I Upgraded( ) Abandoned/)b & ( r� at art M/v k p nn A"l has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NvZ 9—/5Ll dated Installer C-Dr, of r,�-y' C �� ,�!4CDesigner ;1_1A #bedrooms Approved design ow and The issuance of this pe it shall not be construed as a guarantee that the system will ' ncti n designed. Date 6 / Inspector 3 r _____________________________ _'_________________________________________________________________________________-__-___________________ No. �� L.5 4 7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal .pstem Construction Permit Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( ) System located at 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. r Provided:Construction mus be cc pleted within three years of the date of this erm' it. Date , cr+ C) Approved by ~ Commonwealth of Massachusetts Title 5 Official Inspection r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Mashpee Rd. Property Address - -- Wright Owner information Owner's Name is required for every page. Cotuit _ MA_ _ 02635 _ 4/4119 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this forge. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Frank Nunes III _ Name of Inspector saa Company Name -- - Box 841 Company Address --- East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that I 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 CMMR 15.000).The system: ❑ Passes 0 Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority P _ 414/19 Inspector's ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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 perform in the future under the same or different conditions of use. 15ins.doc•rev.6l16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts u Title 5 Officoal Inspection Form a _ Subsurface sewage Disposal System Foam -Not for Voluntary Assessments 39 Mashpee Rd. Property Address --- ----------V--- -- Wright Owner information Owners Name is required for COtUIt every page. _ _ MA 02635 4/4/19 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 masses: ❑ 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: 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): ** There are 2 leaching pits at this property. One of them is apparently of H-10 construction and in a shelled driveway. It is the older of the 2.There is no record at The BOH of its install and it is presumed to be the original installed when the home was built. The pit was excavated and has a 21" cover and approximately 5" thick walls which is typical of H-10 pits.There is a second pit that was installed in 1996, the invert at the D-box is slightly lower to this pit and consequently the flow goes to it. t5ins.doc•rev.6116 Title 5 Official Inspection Form: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 - 39 Mashpee Rd. Property Address — -- Wright Owner information Owner shame is required for every page. Cotuit _ __ MA. 02635 4/4/19 City/Town 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ IV ❑ 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Offidal Inspection Form a _ Subsurface sewage Disposal System Form - Not for Voluntary Assessments 39 Mashpee Rd, Property Address Wright _ Owner information Owner shame -is required for every page. Cotuit __ _ MA 02635 4/4/19 CityTrown State Zip Code Date of Inspection — B. Certification (coot.) 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 Crit eria tares 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 '/z day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachuse-tt:s Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Mashpee Rd. Property Address Wright _ Owner information Owners Name --- —'---is required for COtUIt every page. MA 02635 414/19 City/Town State Zip Code Date of Inspection B. Certutication'(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 coliforrn 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 falls. 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 roust serve a facility with a design flow of 10,000 gpd to 16,000 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins.doc•rev.6116 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 5 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Foy Subsurface sewage Disposal System Form -Not for Voluntary Assessments 39 Mashpee Rd. Property Address ` Wright _ Owner information Owner's Name is required for ' every page. _Cotuit _ MA _ 02635 4/4/19 City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes N ® o Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 274 GPD Detail: Sump pump? El Yes ® No Last date of occupancy: Occupied 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: t5ins.doc•rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Mashpee Rd. Property Address _-- - Wright Owner information Owner's Name ----is required for every page. Cotuit _ MA 02635 414/19 City/Town 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: Pumped April 2018 per owner Was system primped 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 ❑ 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): tSins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 17 Commonwealth of Massachusetts wA Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Mashpee Ind. Property Address Wright Owner information Owner's Name - is required for every page. Cotuit _ _MA _02635 4/4/1 g City/Town State Zip Code Date of Inspection D. System Information (Cont.) Approximate age of all components, date installed (if known) and source of information: Septic tank and leach pit in the driveway per age-of home, new pit 1996 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan).- Depth below grade: 181, feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tarok(locate on site plan): Depth below grade: 12" feet Material of construction: ® concrete ❑ metal ❑ fiberglass 9 ❑ polyethylene El other(explain) H-10 compartment style tank appears to be structurally sound, use caution when digging the outlet cover there is an irrigation line with a low voltage electric line If tank is metal, list age: — years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10000 Sludge depth: 2" 15ins.doc•rev.6116 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 Forms -Not for Voluntary Assessments �ck.. 39 Mashpee Pd. Property Address — — Wright Owner information Owner's Name -----" is required for every page. Cotuit MA 02635 4/4/19 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 >12" ---- Scum thickness trace-1/2" Distance from top of scum to top of outlet tee or baffle >2" -- -- Distance from bottom of scum to bottom of outlet tee or baffle >2 How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 years to prolong the life of the system Grease Trap (locate on site plan): Depth below grade: et --- fe Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 10 of 17 Commonwealth of Massachusetts - y Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 39 Mashpee Rd_ Property Address -- --- Wright Owner information Owner's Name _ is required for -- every page. Cotuit _MA 02635 4/4/19 City/Town State Zip Code Date of Inspection- D. System Information (coat.) 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 9 El polyethylene El 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 17 Commonwealth of MassaChuse-i is - - — Tide 5 Official Inspect'lon Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '� -- 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for COtUIt every page. _ NIA _ 02635 4/4/19 City/Town State Zip Code Date of Inspection D. System Information (coat.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 011 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 D-box is 22" below grade,it appears to be structurally sound, there is carryover in the box, use caution when digging there is an irrigation line directly over the cover 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: 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,• `' 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit ___ MA _ 02635 4/4/19 CitylTown State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: _ ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/narne of technology: -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit in the driveway is the original one, it is damp at this time, 22" below grade, high staining suggests it has failed in the past The pit depicted as "C" on pg. 15 is the newer of the 2, it is 3' below grade, cover raised to 2'of grade, effluent level is 2' below the invert at this time, no indication of past hydraulic failure 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Offidal Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Mashpee Rd. Property Address — — Wright _ Owner information Owner's Name — is required for every page. Cotuit _ MA 02635 _ _4/4/19 City/Town State Zip Code Date of Inspection D. System Information (coat.) 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts V Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cw„ 39 Mashpee Rd. Property Address - Wright Owner information Owners Name is required for every page. Cotuit MA 02635 4/4/19 City/Town State Zip Code Date of Inspection D. System Information (coat.) 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 i O tNS�IIE � 15ins.doc•rev.6/16 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 �. 39 Mashpee Rd. Property Address Wright Owner information Owners Name is required for COtUIt every page. MA 02635 4/4/19 CitylTown State Lip Code Date of Inspection ®. System Information (cont.) Site Exams: ❑ 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: Date — ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Per 1996 compliance 5+feet to adjusted groundwater ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 26'msl and nearby surface water at 6'msl You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 \ Commonwealth of Massachusel s w W Title 5 Official Inspact'on or Subsurface Sewage Disposal System (Form -Not for Voluntary Assessments 7M 39 Mashpee Rd. Property Address - Wright Owner information Owner's Name - is required for COtUIt every page. __ _ __ MA 02635 4/4/19 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 M ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection r _ Sulbsurface.Sewage Disposal System Form- Not for Voluntary Assessments 39 Mashpee Rd. Property Address Wright Owner information Owner's Name — is required for every page. Cotuit _ _ MA 02635 4/4/19 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ © Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms 3 3 (design): Number of bedrooms (actual): — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6116 Title 5 Official Inspection Form: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 M 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 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 G ,'s rfS�llF� C q t5ins.doc•rev.6/16 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 M 39 Mashpee Rd. . Property Address Wright Owner information Owner's Name is required for Cotuit MA 02635 4/4/19 every page. City(rown State .,Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water Check cellar ❑ Shallow wells >15' Estimated depth to high ground water: feet -Please indicate all methods used to determine the high ground water elevation: 'Obtained from system design plans on record If checked, date of design plan reviewed: Date El Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Per 1996 compliance 5-t feet to adjusted groundwater ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 26'msl and nearby surface water at 6'msl You must describe how you established the high ground water elevation: see above r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ''p 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 City/Town 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 HE ram. Town of Barnstable Barnstable Inspectional Services HAStNSTAHLB, MAC Public Health Division sb39• �� . m pry° D�a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 7725 - April 17, 2019 WRIGHT, WILLIAM F &PATRICIA L '39 MASHPEE RD COTUIT, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 39 Mashpee Road, Cotut,MA was inspected on 04/04/2019 by'Frank Nunes III, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Septic tank needs to be replaced. • There are two leaching pits at this property. One of the leaching pits is an H- 10 component and is located under the driveway. This leaching pit must be upgraded to an H2O or the driveway needs to be relocated. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditionally Passes Letters\39 Mashpee Road Cotuit.doc ' f - �t�tom, Town of Barnstable IAMSTABL& + 9� 6 9 Regulatory Services Department Atfp MA'S a Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 ` Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked Iin the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation: ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool '*:-X Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components;etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER a Repair deadline:. Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts LAXT Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 39 Mashpee Rd. Property Address p . Wright Owner information Owner's Name is required for every page. Cotuit ✓ MA 02635 4/4/19 City/Town State Zip Code . Date of Inspection iQ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: c Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that I 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 4/4/19 Inspector's tIgnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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 perform in the future under the same or different conditions of use. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 Citylrown 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: 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): There are 2 leaching pits at this property. One of them is apparently of H-10 construction and in a shelled driveway. It is the older of the 2. There is no record at The BOH of its install and it is presumed to be the original installed when the home was built. The pit was excavated and has a 21" cover and approximately 5"thick walls which is typical of H-10 pits. There is a second pit that was installed in 1996, the invert at the D-box is slightly lower to this pit and consequently the flow goes to it. t5ins.doc•rev.6116 Title 5 Official Inspection Form: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 �M SVB'o. 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 Citylrown 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins.doc•rev.6/16 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 39 Mashpee Rd. Property Address r Wright Owner.information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 Cityrrown 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 Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No 0 ® 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins.doc-rev.6116 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 39 Mashpee Rd. Property Address Wright Owner information_ owner's Name is required for every page. Cotuit MA 02635 4/4/19 City/Town 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form: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 M , 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 ' Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 274 GPD 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Dateupied 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: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): 1 General Information Pumping Records: Source of information: Pumped April 2018 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A System by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 r 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 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Septic tank and leach pit in the driveway per age of home, new pit 1996 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 12" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 compartment style tank appears to be structurally sound, use caution when digging the outlet cover there is an irrigation line with a low voltage electric line If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g _ 2„ Sludge depth: t5ins.doc•rev.6/16 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 M 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 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 >12 Scum thickness trace-1/2" >2" Distance from top of scum to top of outlet tee or baffle >2., Distance"from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 years to prolong the life of the system 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 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 39 Mashpee Rd. . Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 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.): 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 `Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 Cityrrown 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 D-box is 22" below grade,it appears to be structurally sound, there is carryover in the box, use caution when digging there is an irrigation line directly over the cover 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Mashpee Rd. Property Address Wright Owner information Owner's Name is required for every page. Cotuit MA 02635 4/4/19 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type ® leaching pits number: 2 ❑ 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.): The pit in the driveway is the original one, it is damp at this time, 22" below grade, high staining suggests it has failed in the past The pit depicted as"C"on pg. 15 is the newer of the 2, it is 3' below grade, cover raised to 2' of grade, effluent level is 2' below the invert at this time, no indication of past hydraulic failure 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 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Mashpee Rd. Property Address Wright Owner information Owners Name is required for every page. Cotuit MA 02635 4/4/19 Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE 7S--1ff LOCATION 3Y /y'4S epee •r? SEWAGE#:� VILLAGE GP�t!I7`— ASSESSOR'S MAP&LOT!EO "03� INSTALLER'S NAME&PHONE NO. ©/�d LO?S�% 7,2142f9 SEPTIC TANK CAPAcrry 1,660 Gc L i LEACHING FACILM:(type) fly l 41,eJ (size) NO.OF BEDROOMS _3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: .'�`-I� Fzs" Separation DistancdBetwe a the Maximum Adjusted Groundwater Table and Bottom of Leaching Facility s� Feet Private Water Supply Well and Leaching Facility (if any wells exist on site or within 200 feet of leaching facility) /Y Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by µ�RpG i zt;l�3911 t 1 WW 20 i36' 9S 1. !a 1 I � I https://www.townofbarnstable.us/Departments/Assessing/Property_V alues/HMdisplay.asp... 4/22/2019 TOWN OF BARNSTABLE �s'1 LOCATION y`- eta , SEWAGE# VILLAGE" ASSESSOR'S MAP&LOT 494 ,7' INSTALLER'S NAME&PHONE NO. �F�! �`!��d?�/ 7 21-2a Z9 SEPTIC TANK CAPACITY /.660 LEACHING FACIL=: (type) !� �4/�(size) X/G � NO.OF BEDROOMS r BUILDER OR OWNER PERMI TDATE: COMPLIANCE DATE: Separation DistanceB twei th�- Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S� 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 r w e � a t la-— jo 3 s' V= No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for Mtgpo!gai *pgtem Com5tructiou 3Permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: Location Addressor Lot No. Owner's Name,Add es and Tel.No. 60 cel,�_-01" 4 2 6�5' 3 Q PSI Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms Garbage Grinder(�® Other Type of Building /�e.gl eel No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /lam gallons per day. Calculated daily flow 3)rllo gallons. Plan Date 7_ 2"' 76 Number of sheets / Revision Date Title Description of Soil Naturepf Repairs or Alterations(An wer when applicable) 57e O ✓` OiaP l�/�'®llr7G�/,any° /�o GX�I'�?.�/m�l o✓�� Date last inspected:: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his of It Signed - Date Application Approved b Application Disapproved for the following reasons Permit No. �" Date Issued V°- THE COMMONWEALTH OF MASSACHUSETTS e�d 7 — eP3 £S PUBLICWHEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed )or repaired/replaced( on by Arr oGo for /1,1'/1 &-,f<, Z as 3� h111.5 G'� �- h s bb QP constructed in accordance with the provisions of Tit e 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set below: I I� No. . �; Fee � ii THE COMMONWEALTH OF MASSACHUSETTS 'PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Digogar *p!gtem Conotruction 30ermit Permission is hereby granted� to construct( )repair( E)an On-site Sewage System located at 3% �7�5 �E'c? ✓ ��frlJ/ G and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be co ted wit ' two ears of the date below. �- Date: -� i=�'/ Approved by ✓� / �(} Fee No. _ i Y TE COMMONWEALTH OF MASSACHUSETTS *PUBLIC"H�EALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for Mtgogat *pgtem Cow5truction Permit 1, Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: Location Address r Lot No. Owner's Name,Addres and Tel.No. LD Installer's Name,Address,and Tel.No. 7 T�-,43�9 -Designer's Name,Address and Tel.No. 101,0Co�/ Ger�s1 7 �d-4-Ule-e; e Type of Building: O Dwelling . No.of Bedrooms Garbage Grinder Other Type of Building 12005 ejfe-e No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /l f� gallons per day. Calculated daily flow 3. � gallons. Plan Date 7-12 ` Number of sheets I Revision Date Title Description of Soil Nature f Re airs or Alterations(Answer, hen applicable) ilSJ`��� OD�P Date last inspected: Agreements The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b}c his B d of15 It 4 Iff�. Signed Date R Application Approved b Application Disapproved for the following reasons 0 Permit No. ��` F Date Issued / T � ` —————— c TOWN OF BARNSTABLE LOCATION n'0p56�8� 2� SEWAGE a VILLAGE LP�[!/Y' pp ASSESSOR'S MAP&LOT O07—�3E INSTALLER'S NAME&PHONE NO. !10/Td Lo?s'/ 7 7I-$73-E9 SEPTIC TANK CAPACITY LEACHING FACn=:(type)Qr< (Z V1411 (size) b 2/6 NO.OF BEDROOMS 3 `L BUILDER OROWNER PERMITDATE: E�t! //a�j COMPLIANCE DATE: '�S Separation DistancfHen4eF.n Maximum Adjusted Groundwater Table and Bottom of Leaching Facility `f Feet Private Water Supply Well and Leaching Facility(If any wells exist - on site or within 200 feet of leaching facility) Feel Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by pRpF� ; �3911 I 1 WWW 20' 1 I 14 s/a�7G 1 i I i i •@ 4 by 4 ,_4 ' tr�tAok dd `off = n►I :'��d.�s' "1 �` :. ..Yid•, Ix r7 t0tay ",�F ar� .�*s�r '"�'#',',k� = .,�+° °�j''t``t r # �k,t�, a�X;i i r '/rY�l'1/,/ .��,// �j4 (� �� ry�_ . ; `y,L.1 ,.+• Fag`�p 14 - f + £ 3l XF -07 t/ II V . ", I Ht to 4 CERTIFICATION Of SKETCH AND APPLICATION FOR A DISPOSAL %V01tKS CONSTIMC-1-ION 1'Efoll-1'(WITHOUT DESIGNED PLANS) 1, de/'�/e /i;ereby certify that the application for disposal works construction permit signed by me dated ��i61�� , concerning the property located at � e-�? meets all of the following criteria: There are no wellinds within 300 feet or the proposed septic system VT ere me no private welis within 150 feet orthe proposed septic system lie observed groundwater table is 14 feet or greater below the bottom or the leaching rac fill y here is no increase in now and/or change In use proposed There are no variances requested or needed. SIGNED: All DATE: LICENSED SEPTI STEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAllach a sketch plan or the proposed system. Also irthe licensed Installer posesses a certified plot plan, this plan should be submitted). CERTIFICAnON Of SKETCII AND APPLICATION FOR DISPOSAL WORKS CONSTRUCTION 1,LIMIT(WITHOUT DESIGNED PLANS) 1, hereby certify that the application for disposal works construction permit signed by me dated 513� concerning the property located at 3 � e�� 4-�-a'lvl/ meets all of the following criteria: .here are no wcllends within 300 rect of theproposed septic system here ire no private wells within 15o feet of the proposed septic system Tile observed groundwater table is 14 reel or greater below the bottom of the leaching facility 'here is no increase in flow and/or change in use proposed 1 i There are-no variances requested or needed. SIGNED:— DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submittcdl. t y � • "�i.• f you T� Sa . .. .. .• ; � ,�,R'+�,P �M1� � Y � \fir." `b: r. . Q •ZJC � l ' J L9 1 s h a )' sj "J i�' J t v► �071' - LOC&TION ' SEW&(:GE PERMIT UO. VILLAGE IWSTNLLER•5 U&ME ADDRESS BUILDER 5 Q &"F- ADDRESS ANTE PER►A1T ISSUED =``�' 74 - - - 0 ATE COMPLI W ACE ISSUED ; - - - �'�_ �' � � � 9 i / a � �Si � 7 / . p �'. r f �. ',� � � �� w,' \ �, � ��. ,' T �. . . � , . �„ �� . , �. f= �` �\: \�.. s No.......343...... Finc ....... ...... ..... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE TH 1 , "Z , ... ............OF...:... ...it . . ..... .............................. Appliration -for Miipviial Works Tomitrurtion Prruid Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ht P A ......... ....�JD ....D ......................................... ............................................... ------------------------- Loqiot)Adk6j or ]�o No ... . .......... ..... ..................... ........t/.�4.k......lksv...................o........................... ....... _ Ow .......................................... .............................................Address........................................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms-------:&..................................Expansion Attic (A/4 Garbage Grinder (4/6 -1 a4 Other—Type of Building ---------------------------- No. of persons_______---____--_-..----.-- Showers Cafeteria Otherfixtures --------------------------------------------------------------------------- -------------------------------a----- ------------------------------------ 5. Design-Flow............ .0..........................gallons per person per day. Total daily flow-------30.0--------------------------gallons. P4 Septic Tank—Liquid capacityJ0.00.gallons Length................ Width.._......_.__.. Diameter__......._.---_ Depth.._._--_---_. Disposal Trench—No.'____________________ Width----__--__--_--_-_- Total Length-------------------- Total leaching area--------------------sq. f t. Seepage Pit No.._j0qQ------ Diameter.................... Depth below inlet_.....__. ..__._._. Total leaching area_----------------sq. f t. Other Distribution box ( ) Dosing tank ( ) 0 h—loe�;�w 7-6 — 76� ­. . Percolation Test Results Performed by.......................................................................... Date--------------------------------------- Test Pit No. 1----------------minutesperinch Depth of Test Pit-.----______..____-- Depth to ground water...___...--.-.---.-.___.' !X, Test Pit No. 2................minutes per inch Depth of Test Pit._---_-_-...._______ Depth to ground water-_.--.---_-------_--.__. P-' -•-------Soi ...... ...........................I----- JJ 0 Description of l if-------------- A. ...7,64. U ­--------------------- -;;t------------ --------------------------------------------------------------------------------------------------- -----------------------_------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article XI of the State Sanitary Code—The undersign d rth grees not to place the/s s/te in i operation until a Certificate of Compliance has been ssu h r f alt J7 Sigd. ...... ----------------------- --------------------- ................... Date Application Approved By-------- --- - ---- .......... Y--—------------------------ Date ApplicationApplication Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- ......................................................................................................................................................................................................... Date PermitNo .......................................... Issued........................................................ Date 7✓ No....... 2-••. Fim.....1�.................. THE COMMONWEALTH OF MASSACHUSETTS .,� BOARD OF HE LTH _.. t..... OF....... .lLi ........................... Appliratiun -fur Uhipoiial Workii Tomitrurtimn Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System jit: j' ...........................................................- .�� Location-A ddress or Lot No. �-•.— _ Owner a ......••..................................Address.d-�-- ---------•1-t-• --...------••----•---•-••-•-•-----•--•-•-•- Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms______ ----------------------------------Expansion Attic (14�), Garbage Grinder (44) aOther—Type of Building __......................... No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a d Other fixtures -------------------------------------------------------...--------------------- --------------------------------------------------------------------- -- W Design Flow------------ ----------_---------------gallons per person per day. Total daily flow___-___~ ?0_____..._...........___gallons. WSeptic Tank—Liquid capacityloo o__gallons Length---------------- Width...... ......... Diameter-----.---------- Depth.-..--.____----- x Disposal Trench—No..................... Width.................... Total Length_______-____._-•-__ Total leaching area....................sq. ft. Seepage Pit No.1G0o....... Diameter____________________ Depth below inlet..................... Total leaching area.-__-..__._.___-_-sq. it. z Other Distribution box ( ) Dosing tank ( ) 1 6 v ✓"6 i� - 7--6 " 76 Percolation Test Results Performed bY-------- ------ Date---------------------------------- ,� 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..................... -e r ----•-•-- oil ------------------ ------------------------•••-•-Descrlption of S - z ( ' .C /t,rf: (.) ; 't>�>� �a Z. '---•----------------------------------------------------------------------------------------------- W 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 Article XI of the State Sanitary Code— The Li/asr igi e(Vurt agrees not to place the system in operation until a Certificate of Compliance has been issu@d by�thc�of(healt-.� Sign r r -' i.+ # A Date Application Approved BY ;�;/� ----------- ----------t - '--- j ------------------------- - -�:'_.J_.5t__-...�1 Date Application Disapproved for the following reasons----------- --•--•-e•------------------•---------•-------•-------•-------------------•--------------------•------- ................••-•---------------••------....--•-----------.....--------•-•--•--•----•-•-•--•----------•-------••----•--------------------------------.-.-----------------------------------•-------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �. Q.,rrtif irate of f�untplittnrr THI� TO CE&7IFY—,That the Individual Sewage Disposal System constructed) or Repaired ( ) '� by-4-.--f --- -------- �' - - - /`- J,�r i •"'• / � �1�G�, j Installer t ". a has been installed in accordance with the provisions of Krfic-le XI,of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.___g_L,_3_________-_-••-___-__- dated7- ,- 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 No......................... Fa -------- ------•-•• l Bitmpopal/Wor/kp Ton,5trurtinn rrrntit Permis2ion is hereby granted.�--------------------------- --------- ' to C�nruct ( ) or Repir { ) an Indivtdua�Seve Das�osal System (7-`tl . Lam! <� ' &F U 1 U J at No.................................. / � f s.L.4, --------•-----------•--•--•--•---•--------------------•-•----- -------------••----------------- --------------------------------•---•-------------- Street as shown on the application for Disposal Works Construction�Permit Nfo=---------=-----_ -1--_ 74_...__._...._._._.._ ----�'�?i'" --✓l/IfJ rr!1�1 1---- ----n...................... - DATE----------------------------------------=-------- Board of Health(� f FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 5�1 c r41 �lhneli,wG 1ccoCat, leoo Ca. v /1 t t IV LV ! A t i Y ! 1wf 74 lAIG T.-o,ti.tl&je 4?} L AV11,3 ter= ;7Y45` rO AJA.! OXI C ' 'A1-� //N = 4o xr PA 7F.' 7-fZ-76