HomeMy WebLinkAbout0203 MOORING DRIVE - Health ! . 203 Mooring Drive,
Cotuit P
A = 024 116
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Y2D Vineyard Road
C)tuit
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No. �� ^D0 THE COMMONWEALTH OF MASSACHUSETTS FEE (� '
BOARD OF HEALTH
OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( -�Repair ( ) Upgrade ( ) Abandon ( ) - [:]Complete System ❑Individual Components
CT4/^// to L ati.r /`l//r� W OOI f Own ar CO
l Map/Parcem#Af V�J p�p 21i c) —5-7 7, dress
Lot# Telephone#
--B+a F-X LQ)JCA ji1)n I W ( 1114
1 staller's� / Designer's Name
�)Q J-4—1-7—6)6 ess Address
Telephone# Telephone#
Type of Building: eJ Lot Size Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(mi equired) gpd Calculated design flow gpd Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date
eegoof Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS rl I0 dl:ri b-i b( tcon L]Ol(
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu r agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �ZI
Inspections
PPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. ODD— 081 THE COMMONWEALTH OF MASSACHUSETTS FEEX/0�
CY (�( 'IGt_a�I BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: �]'Individual Component(s) ❑Complete System
I
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired(-,.-upgraded( ),Abandoned( )
_ by:at IJ����^^��� �CC�i\/C `�-IUD
2,1,E
/
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans rely tin to application No. dated Approved Design Flow (gpd)
Installer [ 0 1 &1 1�(�)
Designer: A !-,A ) Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. 20I- 08 I THE COMMONWEALTH OF MASSACHUSETTS FEE
( � � 1 GcbLeBOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted Xo Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at Z Ua, A-1 Cr-.) I no r 1 / as described
in the application for Disposal System Construction Permit No.20 l- O a dated
Provided: Construction shall be completed within three years of the date of this perm . 111oc condi 'ons must be met.
Date 2i' I-J Z0 ( � Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
r, FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON
Go
No.Zb �� ^�'O0 1 ,THE COMMONWEALTH OF MASSACHUSETTS FEES`
BOARD OF HEALTH
01l` OF ll t15`t l `,D
APPLICATION FOR DISPOSAL SYSTEM.CONSTRUCTION PERMIT
Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ); [:]Complete System ❑Individual Components
L cation/) /`!// 7 2,C) ✓.-{�-1 (� �- 1 LJac. Co TV
Map/Parcel# 5 d p 2q
-B-+L� ExcnV— Loi# D 114 Telephone#
Installer's Notre" /_. � ��� � Designer's Name
Ln.
^Y k,-1-'6) AalS�lress t��f Address
l0l Telephone# Telephone#
Type of Building. ��J ( � Lot Size Sq.feet
Dwelling—No.of Bedrooms ..S Garbage Grinder ( )
F. Other—Type of Building No.of persons Showers ( ); Cafeteria ( )
Other fixtures
Design Flow(mi equiied) i gpd Calculated design flow . gpd Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title i i. - 14 ./
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator' '' Date of Evaluation
fi DESCRIPTION OF REPAIRS OR ALTERATIONS R 1O d i5 trl b 0f(yn-1?)a)(
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE S and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed .. '� r7�. f�i Date
Inspections
L
FORM V- APPLICATION FOR DSCP DEP APPROVED FORM 5/96
I
Commonwealth of Massachusetts .
W itie 5 Official Inspec ion Form
Subsurface Sewage Disposal System Form .-Not for Voluntary Assessments
M '203 Mooring Drive
. Property Address:. _.. . ....
Ken Bossung
Owner: Owner's Name
information is .required for every Cotuit MA 02635 3/23/13
page. City/Town State Zip Code. Date ofTnspection -
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 A. General Information -
fllling out forms
on the computer;
use:only the tab
1. Inspector:
key to move your
cursor-do not... Matthew Gilfoy..
use the return:
key. Name of Inspector
- B & B Excavation-Inc. ....
I _.
my Company Name
14 Teaberry Lane..
Company Address
rerm Forestdale MA: . 02644
City/Town State Zip Code
508-477-0653 S 113640
Telephone Number License.Number
B. Certification
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:
❑ Conditional) Passes
® Passes.• y . ❑ FadsEl w
t.�
Needs Further Evaluation by the Local Approving Authority . C:�
_. .. ...
3/23/13
Inspector's Signature Date
r .
The system inspector shall submit.a copy of this inspection report-to the Approving Authority(Ward
of Health or:DEP)within 30 days of completing this inspection. If the system is a shared system or
has a desigh.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 th.e 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. : ::::
(Sins•11_/10 Title 5 Official Inspect o iForm:Subsurface Sewage Disposal System-Pagel of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�M 3 203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is Cotuit MA 02635 3/23/13
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:
® 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):
t5ins•11/10 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 203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is required for every Cotuit MA 02635 3/23/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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•11/10 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
�M 203 Mooring Drive
Property Address.
Ken Bossung
Owner Owner's Name
information is
required for every Cotuit MA 02635 3/23/13
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
y
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is required for every Cotuit MA 02635 3/23/13
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
❑ ❑ 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•11/10 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts _ - ..
it e 5 Official Inspection Form
Subsurface Sewage Disposal System Form . Not for Voluntary Assessments
203 Mooring Drive
Property Address:. .... ....
:
Ken Bossung
Owner ...
Owner's Name '
information is _ Cotuit MA 02635 3/23/13
required for every
page. :::,City/Town::: State Zip Code. Date oflnspection :
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 systern 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:
_ . 3
..._Number of bedrooms (desig:n)::: Number:of bedrooms(actual.)-:
- .DESIGN fl 330
ow based.on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): ..
l5ins•11/10 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 203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is required for every Cotuit MA 02635 3/23/13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: , 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2011 = 167 gpd 2012 = 197 gpd
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:
t5ins-11/10 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
GSM , 203 Mooring Drive
Property Address
Ken Bossung
Owner . Owner's Name.
information is Cotuit MA 02635 3/23/13
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
t Other(describe below):
General Information
Pumping Records:
Source of information:
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•11/10 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
wM 203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is required for every Cotuit MA 02635 3/23/13
page. 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:
1979
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 16"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage.
Septic Tank(locate on site plan):
8"
t 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 ® No
Dimensions:
1000 gal
3"
Sludge depth:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is required for every Cotuit MA 02635 3/23/13
page. City/Town 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
36"
Scum thickness
5"
Distance from top of scum to top of outlet tee or baffle 411
Distance from bottom of scum to bottom of outlet tee or baffle
I V.
How were dimensions determined? scour stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up.
I
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-11/10 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
203 Mooring Drive
Property Address
Ken Bossung.
Owner Owner's Name
information is required for every Cotuit MA 02635 3/23/13
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.):
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
t I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is required for everyCotuit MA 02635 3/23/13
page. City/Town 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.):
New d-box installed 3/22/13
J .
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.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM , 203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information.is required for every Cotuit MA 02635 3/23/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1 �
❑ 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.):
At time of inspection leaching appears to be in working condition.Water level 14" below invert. Any
increase in flow may result in 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•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is required for every Cotuit MA 02635 3/23/13
page. City/Town 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: -
I
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
203 Mooring Drive
Property Address
Ken Bossun
Owner Owners Name
information is
required for every Cotuit MA 02635 3/23/13
page. Cityfrown State Zip Code Date of Inspection
D6 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 1 OO feet. Locate
where public water supply enters the building.Check one of the boxes,below:
hand-sketch in the area below
El' drawing attached separately 4
It 13
At= 2, �
A3= 39 ,
�3 = 9,611
3
t5ins•11110
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 s 203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is required for every Cotuit MA 02635 3/23/13
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: >144"
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: 6/30/79
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:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
}
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 203 Mooring Drive
Property Address
Ken Bossung
Owner Owner's Name
information is
required for every Cotuit MA 02635 3/23/13
page. 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
r
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION SEWAGE#
"+n t
VILLAGE SSE 0 'S MAP&PARCEL-'
Mlr
A NAME&PHONE NO. & /l L/C
SEPTIC TANK CAPACITY lex
LEACHING FACILITY::(ty e) (size) 61ao
NO.OF BEDRO MS �J
OWNER 0 I
PERMIT DATE: GQNIPi� CE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet oftleaching facility) Feet
FURNISHED BY ° Z3` ZC30
Mooring Drive 4
`Hater L;
Service
I
t
f441.
26
r
6
32
38
49
J "
C Commonwealth of Massachusetts
,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is required for' rd 524 West 143 New York NY 10031 October 23, 2007
•
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A General Information
'forms on the L lu C1 3
computer,use 1. Inspector:
only the tab key
to move your - Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co. I
Company Name
189 Cammett Road
Company Address
Marstons Mills MA = 02648 :� =
City/Town State jZip Code:,�
508-428-1779
Telephone Number License Numbers
• .�f .. h (YTt
B. Certification CID
I certify that l 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
r� October 23, 2007
In ector'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 perform in the future under
the same or different conditions of use.
07-236 Basta.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is required for 524 West 143`d New York NY 10031 October 23, 2007
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: '
® 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:
Leaching pit was foound empty at time of inspection, high stain lines indicate pit has 18"of effective
leaching. Recommend pumping tank.
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.
07-236 Basta.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is required for 524'.West 143rd New York NY 10031 October 23 2007
every page. City/Town State . Zip Code Date of Inspection
B. Certification (cont.)
B) Systerrf 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: K
❑ 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.
07-236 Bastadoc•08106 '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
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is required for 524 West 143`d New York NY 10031 October 23 2007
every page. Cityrrown 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
❑ ® 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
❑ ® 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.
07-236 Basta.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 o115
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is 52
required fog 4 West 143`d New York NY 10031 October 23 2007
every page. Cityrrown 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.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portionof 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.
07-236 Bastadoc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information
required forts 524 West 143rd New York NY 10031 October 23, 2007
every page. 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
El ® 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?
El ® 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? -
® El available
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)]
07-236 Bastadoc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
up
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is. d
New York NY 10031 October 23, 2007
524 West 143
required for r
every page. City/Town State Zip Code Date of Inspection
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
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if.yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 156,000 gal.
213 gpd.
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
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:
Last date of occupancy/use: Date
Other(describe):
07-236 Basta.doc-08= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts v
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3 I
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is required for rd 524 West 143 New York NY 10031 October 23, 2007
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of.information: None
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)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1980's
Were sewage odors detected when arriving at the site?• ❑ Yes ® No
07-236 Bastadoc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
_ . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is
required for 524 West 143`o New York NY" 10031 October 23, 2007
every page. City/Town State Zip Code Date of Inspection
X
D. System Information (cont:)
Building Sewer(locate on site plan):
1'
Depth below grader - 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.):
r
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 ❑ No
Dimensions: long long x 5.2'wide- 1000 gal.
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 2411
Scum thickness 41'
Distance'from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee orbaffle
10"
How were dimensions determined? Measured
07-236 aastadoc•08106 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
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is required for 524 West 143`d New York NY 10031 October 23, 2007
every page. Cityfrown 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):
Liquid level was found at bottom of outlet invert,tees are intact and clear. Recommend pumping tank
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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):
07-236 Bastadoc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y� 203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is 'required for 524 West 143rd New York NY 10031 October 23, 2007
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
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 ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Oil
_
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.):
No solids or high stains
Pump Chamber(locate on site plan):
Pumps in working order' ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
07-236 Basta.doc-08W Title 5 Official Inspection Form: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
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is required for 524 West 143`d New York NY 10031 October 23, 2007
every page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan,-excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: One 6x6 pit.
❑ 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.):
Pit was found empty with a high stain line indicating pit has 18"of effective leaching
07.236 Bastadoc-08106 Title 5 Official Inspection Forth: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
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is d
524 West 143 New York NY 10031 October 23, 2007
required for r
every page. Citylrown State Zip Code Date of Inspection
1
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.):
07-236 Basta.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is 524 West 143ro New York NY 10031 October 23, 2007
required for
every page. Cityrfown 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.
Mooring Drive
Water
Service
% %
% % % % % % % %
44
26
6
32
38
49
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 203 Mooring Drive, Cotuit MA 02635
Property Address
Nick Basta
Owner Owner's Name
information is required for 524 West 143rd New York` NY 10031 October 23, 2007
every page. City/Town _ State Zip Code Date of Inspection
D. Systern'Information (cost.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to ground water: 20
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:
❑ . Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
USGS topo map and town GIS
You must describe how you established the high ground water elevation:
07-236 Bastadoc•08/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
1HE Town" of Barnstable
�p Tp�
yP� Regulatory Services
SARNST"LE,
Thomas F. Geiler,Director
Public Health .Division
Thomas_McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-8624644 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
nor 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.
RECEIVED
COMMONWEALTH OF MASSACHUSETTS JUL 2 9 2003
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI SFOWN OF BARNSTABLE
DEPARTMENT OF ENVIRONMENTAL PROTEC 0- HEALTH DEPT.
COP
W
h
h
1 o�M SJ 0"
i
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 203 MOORING DRIVE COTUIT,MA 02635 C) -\-\`may — Tr
Owner's Name: HANLEY
Owner's Address: 203 MOORING DRIVE COTUIT,MA 02635
Date of Inspection: 7/7/03
Name of Inspector: (please print) JOHN GRAC1, INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address snd 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 systen-s. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditional l asses
Needs Furt Evaluation by the Local Approving Authority
_ Fails
Inspector's Signature: Date: 'J/7/03
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspec ion. If the system is a shared system or has a design Flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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.
Tith S Incnrrlinn I nrm rrl sr)nnn
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 203 MOORING DRIVE COTUIT,MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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.
n/a 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: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The s stem will ass
Y q P P� g Y Y P
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 203 MOORING DRIVE COTUIT,MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03
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.
_ 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 n/a
"This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 203 MOORING DRIVE COTUIT,MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. , Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
d
Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 203 MOORING DRIVE COTUIT,MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03 .
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant, or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up ?
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS, located on site'?
X _ 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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems`?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
X _ Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 203 MOORING DRIVE COTUIT,MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 1
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):4liz o oV
Sump pump(yes or no): NO
Last date of occupancy: n/a 0
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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): n/a
Approximate age of all components,date installed(if known)and source of information:
20 YEARS BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 pf 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 MOORING DRIVE COTUIT,MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03
BUILDING SEWER(locate on site plan)
Depth below grade: 54"
Materials of construction:_cast iron X40 PVC other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 48"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000 GALLONS"
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffler 33"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
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.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert, evidence of leakage, etc.):
n/a
7
Page 8 Qf 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 MOORING DRIVE COTUIT,MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches, etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
D-BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 MOORING DRIVE COTUIT,MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' OCTAGON leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PTI IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF
FAILURE.PIT HAD F OF LIQUID IN IT AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS
NEVER HAD MORE THAN I' OF LIQUID IN IT.BOTTOM IS AT 7'6".
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
A
Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 MOORING DRIVE COTUIT,MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03
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:
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Page 11 of I I i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 203 MOORING DRIVE COTUIT, MA 02635
Owner: HANLEY
Date of Inspection: 7/7/03
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 10+FT
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LOCATION JvJ� '� �; SEWAGE PERMIT NO.
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INS A LLE 'S N ME i ADDRESS
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THECOMMONWEALTH
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AppfirFation for Di"aviFal Workii Tonstrnrttun V.amit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
...W� _k_ ...............
io es t No
............ .... . .. ............ ..._............ ...... -•-j --• --------------
O ar dress
W . ..................••....................................................... ............. . ... ........................................................................
Installer Address
Type of Building Size Lot V. ........Sq. feet
U Dwelling—No. of Bedrooms ...... Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building .... No. of persons.......6................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ____________________________
W Design Flow......... ------------------gallons per person per day. Total daily flow------Xg r ......................gallons.
WSeptic Tank—Liquid capacity/Q.W.gallons Lengthr.J..... Width., ,1 Diameter................ Depth................
x Disposal Trench—No.--.---••----..._.-.- Widt .................. Total Length.................... Total leaching area........ �---sq. ft.
Seepage Pit No........ ............ Diameter.._. �........ Depth below inlet._ � o._....Total leaching area q.s ft.
z Other Distribution box Dosing to ( )
~' Percolation Test Result Performed by.. ..� ?' Date.`�**./�O/ja Test Pit No. 12- minutes per inch Depth of Test Pit Depth to group wa --- ----
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__ __.._.....
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0 Description of Soil............................................... --------•--------
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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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ed by t oard f health.
Si ne �`7
------------------------ Z.1 ---.K 1..----
Date
Application Approved By--- : . ._
Date
Application Disapproved for the following reasons-...............................=................................................................................
-------------------------------------•---....--------------------•--------•------..........-•-----------------------•••...••----------•--••-----•-----------------------••--------------•-----•••••-----
Permit No. Issued_.. l
ate
'--: ................) -....__. ......
.... Date �,".
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No& ......... .........
THE COMMONWEALTH OF MASSACHUSE77S
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
SS
Installer
ess
Type of Building size Lot,?Py ............Sq. feet
Z Other Distribution box Dosing ta�
Percolation Test Result Performed by............ ----- Date....AP!Awflm
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accord�nce with
the provisions of T IT U 5 of the State Sanitary Code— The undersigned further agrees not to place the t�stem in
operation until a Certificate of Compliance has been issued by thc�,Vbardpf hLlth.
—71
/Y Date
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
THIS IS T0_GE-RTIF,.Y` That-the Individual Sewage Disposal System constructed Repaired
Install
has been installed in accordance with4e provisions of T& 0
,,/y,.he State Sanitary Code as described in the
application for Disposal Works Construction Permit No. ............................ dated.....7 -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
THE�COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Disposal Worhp Tonstri In
Permission is hereby granted.....
............... AV-.
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at No
as shown on the application for Disposal Works Construction Permi J*ted......7-
DATE..........................:�....................................................... Board
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