The URL can be used to link to this page

Home My WebLink About0022 NARROWS WAY - Health ( 22 NARROWS WAY, COTUIT r i I' I; 1 f J I I i Legend 13 Zoning Districts LED I� # # 2. GP-Groundwater Protection i, �t #a1'25 `•, #8 ,�, �.. # 1J,1 WP-Well Protection Parcels Town Boundary 4 � Railroad Tracks # I r ,r`�". - '�,,��. #.2.1 �, Buildings • ._ �" _ P. 1. 1 � ry r' Approx.Building `8 , .� , "� "� `-- s Buildings �t,'. # * ;:e a s ,ti {, s; • "�an.w ��. ^, e ,� �, E $� 5 Painted Lines a,�k' x �a r' ParkingLots �W #�' 1� a 'Y � « i, �,; 4 d�i '4,� .#Y IR 7 °9 w z'i•$ �„ .,r i (Unpaved - #-2fr �' 55 # 65 p 'Driveways 13 Paved . Unpaved '^^ Roads I Paved Road K c Unpaved Road II> yw - dip'� �ta is :? @ a �: ^d Bridge r �` . j Paved Median - Ilrr CC RR �� y ` Streams Marsh le � � x - 13 Water Bodies t 111 16 - �, #,22 �(J _ T � • � Ir�F�C. ►err �t �� ., #� a 36 7 / y l'� Q"`�• �\ n d ui"} ef,"i'M° NAG .. ��,�• S 5 (( n A 111 w � 11 a Map printed on: 1/2/2020 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 026o> O 167 333 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map $08-862-462¢ reflect current conditions,and may contain such as building locations. Approx.Scale: 1 inch= 167 feet cartographic errors or omissions. gis@town.barnstable.ma.us Commonwealth of Massachusetts - Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 22 Narrows Way Property Address Shaffer Owner information is Owner's Name •, required for every COtuit MA 02635 5/29/19 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. Please see completeness checklist at the end of the form. A. Inspector Information _ 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 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/29/19 InspectWgignatue, 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owner's Name information is required for every Cotuit MA 02635 5/29/19 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ►ip Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owner's Name information is required for every Cotuit MA 02635 5/29/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owner's Name information is required for every Cotuit MA 02635 5/29/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts �- lg Title 5 Official Inspection Form 1° Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner information is Owner's Name required for every COtuit MA 02635 5/29/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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. E ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form It Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owner s Name information is required for every Cotuit MA 02635 5/29/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts . IVTitle 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owners Name information is ' required for every COtuit MA 02635 5/29/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes 2 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: March 2019 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owner's Name information is required for every COtuit MA 02635 5/29/19 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: No recent pumping 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owners Name information is required for every COtuit MA 02635 5129/19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El 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 co of latest ( Y ) copy inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1986 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 12,E Depth below grade: feet Material of construction: ❑ cast irony ® 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts �- - ,9 Title 5 Official Inspection Form It Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owner's Name information is required for every Cotuit MA 02635 5/29/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 61' 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: 1500g F 181 1 Sludge depth. Distance from top of sludge to bottom of outlet tee or baffle >12 lot Scum thickness >2tt Distance from top of scum to top of outlet tee or baffle �2tt 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 t5insp-doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,io Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owner's Name. information is required for every Cotuit MA 02635 5/29/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: t 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, ( p p 9 liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 . t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 AN Commonwealth of Massachusetts r - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owner's Name information is required for every COW it MA 02635 5/29/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" I 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 12" below grade, average condition for its age t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner information is Owner's Name � required for every Cotuit MA 62635 5/29/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): 1' *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts - (o Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner information is Owner's Name required for every Cotuit MA 02635 5/29/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit has 6"of effluent at this time, stain line about halfway up the sidewall, bottom of pit is 8' below grade, no indication of past hydraulic failure 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ,�-a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 22 Narrows Way Property Address Shaffer Owner Owner s Name information is required for every COtuit MA 02635 5/29/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner information is Owner's Name - required for every Cotuit MA 02635 5/29/19 . page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 a t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 t ASSESSOR'S MAP NO.02I PARCEL _'' LOCA T ION LOT Z'B �� k' SEWAGE PERMIT NO Au 2 / V.1 L L A-0 E �INS AL ER'S NAME. i A,DDRESS It `�JIIUILDER OR QwNER '� f3R�2 11�GG GATE PERMIT ISSUED DATE COMPLIANCE ISSUED 6 qj L44= +_ i� Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner. Owner's Name information is required for every Cotuit MA 02635 5/29/19 page. Cityrrown State .Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ' ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 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: n/a Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: 4'seperation per 1986 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, site is at 54'msl and nearby surface water is at 12'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. t5insp.doc•rev.7/26/2018 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts �s ,p Title 5 Official Inspection Form 1° Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Narrows Way Property Address Shaffer Owner Owner's Name information is required for every Cotuit MA 02635 5/29/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed-& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,;2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 PROPERTY ADDRESS: Z2_-jLrraws._..Id- _________ -- Coruit ----------- ' 02635 , On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 .. 1-1500 gallon septic tank, . 2 . 1-Distribution box . 3. 171000 gallon precast leaching pit . . Based on my Inspection, 1 certify the following conditions: 4. .This is a .title . Fi.ve Septic System,. ( _78 , Code ) 5.' The septic system is in prop.er_ working order " at the present, -time . 6. Pumped septic tank at time of inspection . 7 . Waste water is forty two inches below the invert pipe . of the leaching pit . SIGNATURE.*f N a m e:_,L a,-Aosa m D.om sixes------ Company: Jose,2h_P.., Macomber & Son , Inc . Address:_ Box_66_ _ CentervilleL Ma__02632-0066 Phone:___508 775_3338_______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks•Ce$6pools•Leachtields Pumped 4, Installed Town sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 . -��.. • � MAR 6 2000 � . � . TOWN OF BARNSTABLE HEJ L H DEPT. �. 4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-6600 TRUDY CC ARGEO PAUL CELLUCCI DAVID B. STRI Governor Coma slit SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART A CERTMCATION Pr,perry Address: 22 Narrows Way Nam.of own..J a m e s Mann Cotuit ,Mass 02635 Addrs+ofOwnw: Dee of inspection: /8/00 Name of Inspector:(Pteaso Print)J o s e p h P.Macomber Jr . 1 am a DE3 oved system Inspector pursuant to Section 16.340 of Thie 6(310 CMR 16.000) CornpanyNam.e J.P.Macomber & Son Inc . MaMNAddress: Box 66 Cantarvi 11 A 1Mncs 02632 Telephone Number: 5()g 75 CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below is true, accurste and complete as of the time of(rupection. The Inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: Passes � w Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Falls y Inspectors Siynat . i J�" Data: a�!-O� The System Inspect shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)whNn thirty(30) days o 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 own, fiat)submit the report to the appropriate regional office of the Department cKmvironmantai Protection. The original shouldbe,sent topes system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS r revised 9/2/98 Page I of 11 • A � C.t Printed on Racyc4d P+par SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE6nON FORM PART A CERTiRCATiON(continued) propenyAddr.aa; 22 Narrows Way Cotuit ,Mass . Owner. James Mann Daa of Inspection: 2/8/0 0 INSPECTION SUMMARY: Check A, B, C, of A A. SYSTEM PASSES: t have not found any information which indicates that any of the failure conditions described in 310 CMR 1S.303 exist. Any failure uiteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: VO 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. Indicate yes C no,or not determined(Y.N,or ND). Describe basis of determination in all Instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial Infiltration or exfiltration, or tank failure is imminent. The system will pass Inspection if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced .vp - The system required pumpMg-Tnore than-four-dines s Yeardue to broken or obstructed pipe(sl. Thesystem wiU•pasr•- Inspection if(with approval of the Board of Health): - -- broken pipes)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) pr.pdyAd&.: 22 Narrows Way Cotuit ,Mass . owner: James Mann Date of kmWocd= 2/8/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A5 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is falling to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CUR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICHYMIPROTECT THE PUBLIC MEALTHAND SAFETY AND.THE EI&MONMENT Cesspool or privy is within 50 feet-of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well. AV The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid).- 3) OTHER WA revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Pr*wtyAddreis: 22 Narrows Way Cotuit ,Mass . Owner: James Mann - Daft of Inspection:2/8/0 0 D. SYSTEM FAILS: You must Indicate either"Yes" or"No" to each of the following: _h I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No ,r r/ -cesspool. Backup of sewage into4eciBt�-w-e/ete component an overloaded orclegged•S,AS�or m 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 di �7 tri6utioh o above outlet Invert due to an overloaded or clogged SAS or cesspool. �� L y�v Liquid depth in cosepool Is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public well. 1 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organio-compounds, ammonia nitrogen-and nitrate nitrogen. - E. LARGE SYSTEM FAILS: 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: ivy. The system serves a facility with a design flow of 10,000 gpd or greater(Largo System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No / f/ the system is within 400 feet of a surface drinking water supply the system•is-within 200 feetofa-tsilwtarytoaeurfoo"Ankiop 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforptation. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION I Property Address: 2 2 Narrows Way C o t tl i t ,Mass . Owner James Mann Date of Inspection:2/8/0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: A a.p.d./bedroo . Number of bedrooms&�desig : Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yes or no):L�-ews Laundry(separate system) ,�s or oo If yes,sepawalnspectlon.required _ Laundry system Inspected Iva; or no) _ Seasonal use(yes or no): / 1 h er f. X Water meter readings,If ava ble(last two year's usage(gpd): ��6 Sump Pump(yes or no): L_ 11 � J9.1 e ,�' Last date of occupancy: *�-10 F (5 COMMERCIALIINDUSTRIAL• �7�c• J Type of establishment: Design flow: god ( Based on 15.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or noulff Non-sanitary waste discharged to the Title 5 system:(yes or no)_A,'1 Water meter readings,If available: - Last date of occupancy:,&)4 OTHER:(Describe) AW Last date of occupancy: 1 GENERAL INFORMATION PUMPING RE 0 DS and sourc of infor ation:�. f��da � � tC.� System pumped as part of inspection:(yes or no) S If yes,volume pumped: al ns Reason for pumping- TYPE TYPE OF YSTEM 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) UA Technology'^e�t .Attach copy of up to date operation and maintenance contract Tight Tank �UlY Copy of DEP Approval Other i APPROXIMATE AGE of all components, date instaged{if known)-and souroe.v 4Rformation: Sewage odors detected when arriving it the site:(yes or no) -44 revised 9/2/98 Page 6of11 I • , SUBSURFACE SEWAGE DISPOSAL SYSTEM WS�PECTION FORM PART B CHECKLIST Prop"Addiress ; 22 Narrows Way Cot•uit ,Mass . Owner: James Mann Daft of Inspection: 2/8/0 0 Check if the following have been done:You must indicate either"Yes" or'No" as to each of the following: Yes N•-1� Pumping information was provided by the owner,occupant, or Board of Health. • -None of the systemcompanants haaabeen pna►Pad4a;4 •Jeast•two•awoalm and-4ba7ystern hssbaeowcatair+ywwW flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was Inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The site was Inspected for signs of breakout. _ r All system components,a�Kduding the Soil Absorption System,-have been located on the site. _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was Inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: iZ Existing Information. For example, Plan at B.O.H. _ Determined In the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable) 115.302(3)lb)) _ The facility owner.land.occupanis.lf diiferatst from.n�wnad.+were prnukiad with t^f�•,*+AHoaon*►+�p�^p.sinra�,M� �t SubSurface Disposal Systems. i i i revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Narrows Way C o t u i t ,Mass . Owner: James Mann Date of Inspection: 2/8/0 0 BUILDING SEWER: •(Locate on site plan) Depth below grade:—d Material of construction:40 cast iron//40 PVC4 other(explain) Distance from private water supply well or suction line Diameter -y"_ Comments:(condition of joints,venting;evidence of loakageretc.) Joints . S&M TANK• f,; (locate on site plan) !V Depth below grade: Material of construction: Yconcrete;j2,:Ynetal4/eFiberglass 42�Polyethylene I�iother(explain) If tank Is metal,list age Js.ag/je.confirmed by Certificate of Compliance (Yes/No) Dimensions: r it), Cr ' '4' ) 1 �8 Il r Sludge depth: T �• Distance from top of sludge to bottom of outlet tee or baffle: (� Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outlet t e or baffle: How dimensions were determined: Comments: (recommendation for pumpi ,condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet inert,atructuraFtintegrity, . �evidenceof leakage,etc.)'-ump septic tank annually, GarhagP His sisal ; s present - Inlet & ontl Pt. rPPg era n p! erg The to k 4e --tpoe`ural __ GREASE TRAP- (locate on site plan) Depth below grade: Material of construction: oncreteq�metalfAFiberglas44( LPolyethyleneA2other(explain) Dimensions: Afi Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: A Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert,structural Integrity, evidence of leakage,etc.) —Grease tra is not present - revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corntimbed) Property Address: 22 Narrows Way C o t u.i t ,Mass . Ow"w. James Mann Deft of knpectkm: 2/8/0 0 TIGHT OR HOLDING TANK-Aj! L(Tank must be pumped prior to, or at time of, inspection) (locate on she plan) Depth below grade:-.ALA Material of construction:�2concrete A49metal VlFiberglasaN�±Polyethyleno4l2other(explain) MA VA Dimensions• A/A Capacity: A/A gallons Design flow:, V# gallons/day Alarm present AM Alarm level: Alarm in working order:Yes4/g NoM4 Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Tight or holding tanks are not pro opt DtSTRisunON BOX:_L' (locate on site plan) Depth of liquid level above outlet invert: Al,(2 Comments: (now-If level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) — — Distribution box has ana -Iateral , No evidence of solids carry over . No PvidPnre of 1PnkagP intn or not of the hnY PUMP CHAMBER•V - • rst (locate on she plan) N Pumps in working order:(Yes or No) A/A Alarms in working order(Yes or No) 40 Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) umo chamber is not present revised 9/2/98 Page aof11 SUBSURFACE SEWAGE Dl;PCSAL SYSTEM INSPECTION FORMA Pl.:;7 C SYSTEM INFCF l,'.Al-ION(continued) Property Address: 22 Narrows Way Cotuit ,Mass . Ownw: James Mann D.te of i"Pection: 2/8/0 0 SOIL ABSORPTION SYSTEM(SAS). (locate on site plan,if possible;excavation not required,location may L r.pproximsted by non-Intrusive methods) If not located, explain: Type. leaching pits, number: �t leaching chambers, number. t leaching galleries,number:, leaching trenches,number, length: leaching fields, number,dlmV&Ions: overflow cesspool,number:_ , Alternative system: . Name of Technology: Title Five 78 Code Comments: (note condition of soil, signs of hydraulic failure,level of ponding, dmn•;. soil, condition of vegetation, etc.) Loamy sand to sand No signs of hydraiil i r fni 1 l,rP nr f ndi ng Snit - 2r-a dry . Ve-getatien fie- 1 CESSPOOLS: (locate on site plan) Number and configuration: 0 Depth-top of liquid to inlet invert: Depth of solids layer: ° Depth of scum layer: Dimensions of cesspool: .y Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of Inspection)_____ Cesspools arp not prPCPnt Commenu: (note condition of soil, signs of hydraulic failurs,.level of ponding,<cn::it!cr: of.vegetation, etc.) esspoo s are not present _._. PRIVY: (locate on site plan) Materjals of construction: Dimensions• Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, of vegetation;etc.) rivy is not present , revised 9/2/98 II • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Narrows Way C o t u i t , Mass . owner: James Mann Date of Inspection: 2/8/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECIPON FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Narrows Way C o t u i t ,Mass . Ownw: James Mann Data of Inspection: 2/8/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date webaite visited Observation Wells chocked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to GroundwateytL Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record -ZtObserved.Site(Abutting property, bservation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps -A�-/Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11ofIt f ' •wwgT�.-n1��•rrnrawv..nrlrmta,nrrnarn+.++w►+.r�n+•m lr�+��.+.+r.v��n ran t•�-�..�.�:...-.r.. TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL (SYSTEM INSPECTION FORM - PART D•- CERTIFICATION �•TT•ITT•:•t: —T.IIR�. 'r'1Jn►wI'.1.•.IfT w -nrr-vrm—l•IrltRw.Yll�-rT.•r+w'I —TYPL OR PRINT CI.EARLY— PROPERTY I NSPECTE-D STREET ADDRESS 22 Narrows [,gay Cotuit ,Mass . ASSESSORS MAP, BLOCK AND PARCEL 003 00a OWNER' s NAME James Mann- PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J.P.Macomber & So-fi' Inc . COMPANY ADDRESS Box 66 Centerville , Mass . 02632 street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - -333b FAX ( 508 1 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and omplete as of the time of >inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: I ' ZysteLri PASSED ' The inspection which have conducted has not found any information which indicates that the systern fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature % s Date �Q= copy of this c rtification must b provided to the pWNER, the BUYER Dn6 where applicable ) and they 130ARD (DV ILZAL'111. * If the inspection FAILED, th`e owner or""h orator shall upgrade pgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 15 , 305 . partd .doc } alb YJ p" THE COMMONWEALTH OF MASSACHUSETTS / B0A RDA I i EA �W 4� OF....... ........... . y� Appliration for Uiopooal Works onoirnrtion permit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at ..........�/�O7.r/5 l!�_.. t. ... ............................................................ ati - re or LotNo.�/ .......... �. �� - .....................................__.... w er ess . -----------• •---�----• ---- ---......-. -- •--... ----•- ----spy_____—_____—_-�'_'s'_'__'� � � Installer Address Type of Building Size Lot... . ...Sq. feet U Dwelling—No. of Bedrooms............ ----------------------Expansion Attic ( ) Garbage Grinder (e — '� Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures ------------------- ----•• - W Design Flow..................................... gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity ��._gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No. ..__•_-.._._._-•-•-- Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No......../--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by.................... ............--....................................... Date........................................ a_1 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........................ •----------------------------------•--•-•-------------------------••----------..........--•---•-•---......................................................... 0 Description of Soil........................................................................................................................................................................ x U ----•••------•-••••----•---••--•-•••........•--•---•--•---•-••••----------•-----------------••--•----•----•-------•----.....------•---------••-----------------••-•••----•---------••----•--•--•----•- W ------------------------------------------------•--------------------------------------•-•-------------------------------------------------------------------------••-----------------------------_...-- VNature 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 iIT?, . 5 of the State Sanitary Code-The undersigned further rees not to place the system in ope ation t erti-sate of Compliance has been issued b th o d of h It Sig ed !!�/ -•-----------------------------............. -!��......_ ..._ PPli ti n Approved By •-----. ................. J a l_ Date] Application Disapproved for the following easons---------------•-••-----•-•-•--••----•---•-•---••---•-•----•------•--••---•••••••••-••-••-----••------•••-•-•-- ................................... ...................................................................................................................................................................... Date Permit No...... �� ....................................... Issued__... - Date Y• Bey ' � No..... Fim---.-`'. ------------ A THE COMMONWEALTH OF MASSACHUSETTS BOARD OJF HEALTH r .. ....... .................OF........ ,_ -. `] f App iration for Disposal Works Tonstrnr#inn rrmit Application is hereby made for a Permit to Construct (t10 Repair ( ) an Individual Sewage Disposal System at ........ t Lpocatio�nf �A*ddres .I r7 or Lot No C` •__..........y • ..... "" .,. ........ri.. :....... ............. .�a,T, J ,! ........_.._.................___' Owner d' Address (� `11 Wa t f Yf rF t..................... �"° p P 'n r""a "" :Z! {s ........._....... ................ ........ ....... ................_ ............ .....P. ....- _ .. Installer "� Address i>• QType of Building 3 Size Lot_______s'` !'e`...Sq. feet U _____________________Ex Expansion Attic Garbage Grinder Dwelling—No. of Bedrooms__._.....__._..:_ p ( ) g '4 Other—Type of Building No. of persons____________________________ Showers — Cafeteria 04 Other fixtures -------------------------------- <11 W Design Flow............................................____________gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity./K' _gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..:.................. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_________ ......... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by............................................ ----------------------------- Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p4 --•------------------•-------••-----•----...------------------......._._..........._...._._...•-----......................................................... 0 Description of Soil...................----•--------...-•-•-----...--•--------------•--•--•-----•-•----•-----------•---•--•-----------------------••--------•----•-•-----------------...--- U ...............--........................................................................................................................................................................................ W -----•----•------------------•--•-------•-----------••-•---------•--•-------•---------•--•--••--------------•----------••--•-------...---••---------------------•------------.._..........---......... 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 TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation ti Certificate of Compliance has been issued by the*board of health r �s Wit, '� � PPlica i, Approved By... ---------•----•-------- ., _.. ..--------- --- at ...... Date Application Disapproved for the following reasons_____________________________________________•-------------------------------------------._...__.._._.........._ ......................................................--•---...-•----------------------•--•-----•--•----'---•-•--...---------•--•--•-•----------•--•-................................................ Date - PermitNo.----- ...?Pt......................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH ............. ....a---.`. .........OF......... . ....................... %'-wCrrtif iratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed,(' ) or Repaired ( ) bn f_�m y--e-......................................................J....--........---•--•-•---•-------........ y._.._....... Installer at--------•---------� ..---•------�s��'._---••--N_?� ��'-'- ,: w - --------•-MTv-I has been installed in accordance with the provisions of TITLE 5 of he State 'Sanitary Code as described in the application for Disposal Works Construction Permit No------ ............ dated__..?__. j z.1f-i>3--0--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS A GU RA TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................................6.. !. ............... : Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH L. ........0F.............. !�!� L.L�.................... FEE...........�........ No............... ........ ........ 4� Disposal Works C'Eunstrudionn mit Permission is hereby granted..................... -------=ri-- .............. ..._ to Construct ( ) r Repair ( ) an Individual SewagCce Disposal System ' ca"C J T at No.----•••........ ..... ..1 - ..:. �1 �c Uw �7.----•- ........................................ i � . .^ l J - , LA j fl Street qq,. t� as shown on the application for Disposal Works Construction Permit No....._-�-7 a'Jate�__.. ....................................... - .......................................... ._ ---- oard of Health DATE--- ----%I --------•- ... ------- FORM 1255 HOBBWARREN, INC., PUBLISHERS , -D ATT C-h --------------'- .,4-'FAMA LY,- 3 al , G OR 0 0 r,4' :' po Al b6 ''1 3 - 17 T gm. y '..J��'1..SI'`�r- F�{�� { :V�Jj��W `'Iona Gqt; -/,(� S/!?I� �'4 .' t,,; � � /�, ` r�.- ;'� t ;n i491:. A. 7 DE W A'L� U S, P, "k- t p7 '%777 is IN Afl- T 4! L T '-TER 4. .3 -T.!lr.T tt N-04 i At. V" L2 7 d' IP 4-�I Lo9 7i -A 4 -A CH 7W "NU7 Xe4AJ F/0 W, )NlUeem /3 A "N O c4r- ri;, LA Vo VVqn--P 1 THA7 /7 Nsli C- :rQc belu 4c.w 4 H LP-E 0 1 1 O�' C4>NPLY W, 1A 64 'AfJO sfTeAeiL ;V4 � 7&WA.) C� ju rr -P CA IS A -wo"/-A) C T- ANZ 12,CA -Ty, 7/2 TA&G,7b 00 AM l)J6?-%)MCPJT— r A3 A t7 %86 -0-se ASSESSOR'S MAP NO.U�I PARCEL " LOCATION Low Z-`d SEWAGE PERMIT NO VjILLAGE co Lo SINS A L"LlR'S -NAME a ADDRESS 4& 1 (2 i i A G (Q T 3 T-4- 8 11-1,rf UILDER Oir fAE A1e>e_.1V,(134 6ZR � DATE PERMIT ISSUED DATE COMPLIANCE ISSUED V� r �^ JN i ` �� cpo � w i 7 V �du ®70 �_1 i ( _ /117 I I . (13nss) 3 3 N V I I J W 0 3 31V0 a3nSS1 liWb1d 31Va 7,7� �13wM I IMP violin SSaM0 - V 1 3 W V N S.�l ..1,1 VfsNIr� 97 > o C-/ Y WM3d 39VM3S �Z to NolIc) oI 133bHd ON dHW, S,dOSS3SSH James Mann 22 Narrows Way Cotuit ,Mass . 2-Bedrooms Garbage disposal . 1-1500 tank. 1-BOX . 1-1000 L. P. r ;:. � �— � � � � � _ .9 \\ �� \ � ��, '�� . / I ® � i/ .-� � i i. i � /� i � / �i� �` i �. / /� �� C� +�. �t5 '. .a James Mann 22 Narrows Way . Cotuit ,Mass . 2-Bedrooms Garbage disposal . 1-1500 tank. 1-Box . 1-1000 i Ice 6 r � . j/ / ,I ,l