HomeMy WebLinkAbout0091 NICKERSON ROAD - Health 91 Nickerson Road
Cotuit }�
A= 018-083
' r
e
• Commonwealth of Massachusetts ;
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;
91 Nickerson Rd
Property Address
k• Arthur Hughes ,
Owner Owner's Name "
information is m .
required for every Cotult } MA 02635 4/6/12
page. Cityrrown State Zip Code Date of Inspection -
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:when :A. General Information
- �-filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your ' 4
cursor-do not Ricky L.'Wright..
use the return
key.
B &B Excavation,lnc:
I
rab Company Name L ... �
14 Teaberry Lane
Company Address
Forestdale MA 02644
4 City/Town f State Zip Code
508-477-0653 S14595'
Telephone Number ; License Number
-B. Certification-
I certify that l have personally inspected the sewage disposal system at this address and tl aj the--,
information reported below is true, accurate and complete as of the time of thelspection. Tie inspection
was performed based on my training and experience in the proper function andmmaintenance of onsite
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1, .34Q,�f
Title 5(310 CMR-15.000).The system: . -711
s 53
® Passes ` ❑ Conditional) ` i S y Passes ❑ Fai ls ,
❑Y Needs Further Evaluation b the Local Approving Authority
'
Y PP 9 Y 1 7
s 4/6/12
Insp tor's Signat e' 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.
t5ins•11/10 q I v
Title 5 Official In pe, on Form:Subsurface Sewage Disposal System-Page 1 of 17
h..
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
91 Nickerson Rd
�M -
Property Address ?
f
Arthur Hughes '
Owner Owner's Name
information is required for every Cotuit MA 02635 4/6/12 j
page. City/Town State wZip Code Date of Inspection '
B. Certification (cont.) a
Inspection Summary:.Check A,B;C,D or E/always complete all of Section D
A) System Passes:
T f
® I have not found any information which indicates that any of the failure criteria described
". int310 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 vvith,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.
El Y. ❑ N ❑ •ND (Explain below):
'R
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 91 Nickerson Rd
Property Address f
•Arthur Hughes
Owner ; Owner's Name
information is=required for every Cotuit MA 02635 - 4/6/12
page. Citylrown 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 ob
structed ucted pipe(s)
s or due to a broken settled or uneven distribution box. System will
P ,P O y
pass inspection if(with approval of Board of Health):
t ` ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y. El .N ElND (Explain below):
❑ distribution box is leveled or replaced - ❑ Y ❑ N ❑ ND (Explain below):
El 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:
El 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:
Ej Cesspool or-privy is within 50 feet of a surface water
F
❑ `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
= v Title 5 Official Inspection Form , ,.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Nickerson Rd
Property Address +
f
Arthur Hughes W
Owner +' Owner's'Name
information is'
required,forevery"' Cotuit MA� '02635 4/6/12 `.
page.. - CityTrown State Zip Code Date of Inspection
B. Certification,(cost.)
;R 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: '
El" • 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
p ' supply.
❑ "The system has a septic tank and SAS and the SAS is within 50 feet of a private water
t 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:
/ **Jhis,systern,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: .
r '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
y ❑ Z 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 '/2 day flow.
t5ins•11/10 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 91 Nickerson Rd
Property Address
Arthur Hughes
Owner Owner's Name
information is Cotuit MA 02635
required for every 4/6/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.) r
Yes ;No r
;El. Required pumping more than'4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ x- ® 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.
w ❑ Z Any portion of.a cesspool or.privy is within a Zone 1 of a public well.
El ® 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.]
El "E 4` 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
y. ® 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 1,5,000 gpd.
. t
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
a
❑ ❑ the system is°within 400 feet of a surface drinking water supply
❑ ❑ the system is within 260 feet of a tributary to a surface drinking water supply
❑ ;El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or.a mapped Zone Il 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.
t5ins•11110 y Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 17
Commonwealth of Massachusetts /
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =
p
'91 Nickerson.Rd.
a M
�f
W_ property Address :: r
Arthur Hughes {
Owner -4 Owner's Name-
information is
required fog every COtUit _ + MA •V635 •�4/6/12: t
page. Cityrrown _ , State Zip Code 'Date of Inspection
'C.-Checklist F
w a
` Checkaif the following have been done:You must indiicate"yes"or"no"(as to each of the following:
-Yes' Mo
r Y
g:•❑,, :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?
. .r' ❑f Has the system received'normal flo`ws'in.the previous two week period?,
Have large volumes of water.been Introduced to the system recently or as part of
4 ❑ ® { ~this inspection? .
Were as built plans of the}system obtained and examined? (if they were not
t
®Y1R available note as N/A)
❑_ ,T. •°Was the facility'o' r.dwelling inspected for.signs of sewage back up?
` 0 Cl ,,'Was the site inspected for signs of break out?
Z ❑ Were all system components, excluding the SAS, located on site?
_ F® ❑ . . --Were the'septic tank manholes uncovered,'opened, and the interior of the tank
k4 inspected for the condition of the baffles or tees, material of construction,
.� dimensions, depthof liquid„depth,of sludge and depth of scum?
as the facility,owner(and occupants if different from owner) provided with
a ❑ information on the proper maintenance of subsurface'sewage disposal systems?
,x The size and location of the Soil Absorption System (SAS) on the site has
r - been determined based on:
Z # �` ❑ Existing information.,For example; a plan at the Board of Health.
v
Determined in the'field (if any of the failure criteria related to Part C is at issue
`1,,E] approximation of distance is unacceptable)'[310 CMR 15.302(5)]
D. System Information
Residential Flow'Conditions: •�
. t Number of bedrooms (design):. a Number of,bedrooms(actual):
DESIGN flow based on 310 CMR`15.203,(for example: 110 gpd x#of bedrooms): 220
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17'
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 91 Nickerson Rd
Property Address
Arthur Hughes
Owner Owner's Name -
information is Cotuit MA 02635 4/6/12 required for every ,
page. CitylTown .. ' State Zip Code Date of Inspection
p A
D. System Information
Description:
Number of current residents: f 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
Seasonaluse? r ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
,.
y .
Sump pump? ❑ Yes ❑ No
Last date of occupancy: a 3 months ago
' Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
t 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
r . "
a Commonwealth of Massachusetts
w v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .,
91;Nickerson Rd
Property Address
Arthur Hughes
Owner Owner's Name
information is
required for every Cotult• MA 02635 - 4/6/12
page. City/Town r State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: 2 bate
- 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: - r
❑ # , 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):
(Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 ®fficial Inspection Form
4,
Subsurface Sewage Disposal osal SystemVoluntary Form Not for Volunta Assessments
P a
_91 Nickerson Rd '
Property Address;
F
Arthur Hughes x
Owner.. 3 Owner's Name
information is,
page. every
City/Town State Zip Co "Date of t
re uired for eve Cotuit _ MA 0263
` '' de ' Date of Inspection
D. System I°nformation (cont) r
Approxim{ateJage of all components; date installed (if known)and'source of information:
30 -t years A
' "Were sewage odors detected when arriving at the site? . ❑ Yes ® No
=Building Sewer(locate on site plan):.
` Depth below grade: - feet
Material of construction:
cast/clay
® cast Iron-' ❑ 40 PVC ,® other(explain):
. .4 -'
Distance from private water supply well'or suction line:`
feet
. , .Comments,(o, n'c6ndition of-joints, venting,`evidence of leakage, etc.):
.: At time'of inspection, building sewer appeared to be.in'good working order no sign of leakage or
`blockage. ,.
M
Septic Tank(locate on site plan): 1K s t. Ilk
t" Depth below grader 7, #
feet
Material,of construction':
'❑ concrete ❑ metal ❑fiberglass'' ❑ polyethylene ❑ other(explain)
' .R' " � — • tax • 'p°- '''�t ,. f '
" If tank is metal, list age: '
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
—Dimensions
Sludge depth: V ..
t5ins•11l10 " • • ° - Title 5'Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
y. r
Commonwealth of Massachusetts
02
Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Nickerson Rd
M -
Property Address
Arthur Hughes
Owner Owner's Name
information is required for every Cotuit _ MA 02635 4/6/12
page. City/Town State Zip Code , ` Date of Inspection .
D. System Information ,(cont.)
4
" Septic Tank(cont.)
• 4
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from m top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle '
r How were dimensions determined? `
Comments (on pumping recommendations, inlet and+outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
i
,< Grease Trap (locate on site plan):
Depth below grade: • feet
Material of construction:._
- ❑ concrete . ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain):
. ' .4.
Dimensions:
Scum thickness "
Distance from'top of scum to top of outlet tee orbaffle' .
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: 4 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" , T
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 M 91 Nickerson Rd
Property Address ,
Arthur Hughes
Owner Owner's Name
information is Cotuit _ ,r MA 02635 *, 4/6/12"-
required for every '
page. _ Cityfrown • State Zip Code Date of Inspection-
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 grader
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: ;
Capacity:
•gallons
Design Flow: gallons per day
a,
Alarm present: ❑ Yes ❑ No
Alarm level:-,', `t =t -_ Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date f
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required): Is•copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
R
{ Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Nickerson Rd
Property Address
Arthur Hughes
Owner Owner's Name
information is •required for every Cotuit MA 02635 4/6/12
-
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
r Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
_
Pump Chamber(locate on site plan):
Pumps in working.order: ❑ Yes ❑ No
Alarms in working order: ❑ -Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
' r
Soil Absorption System (SAS) (locate on siteplan, excavation not required):
y 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
91 Nickerson Rd
Property Address
< 'Arthur Hughes *..
Owner Owner's Name ,
information is
required for every ` Cotuit MA 02635 ** -4/6/12 `
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)'
Type: ;
❑' leaching pits number:,
EJ leaching chambers ,, number:
`' ❑ .leaching galleries , number:
• 0 x leaching trenches number, length:
❑ leaching fields number, dimensions:
® - overflow cesspool number: 2 in series
❑ -. innovative/alternative system-
Type/name of technology:
- µ 4 Comments (note condition of soil; signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of,inspection cesspool#2 appeared to be in working order,no sign of back-up ,cesspool was
dry.
, y
Cesspools (cesspool must be pumped as part of inspection) (locate'on site plan):
• Number and configuration 2 in series
Depth top of liquid to inlet invert r .dry
Depth of.solids layer M dry
Depth of scum layer dry
Dimensions of cesspool 6x6
Materials-of construction -` block
Indication of groundwater inflow._ El Yes ® No
- _ W
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Nickerson Rd
Property Address ti
Arthur Hughes
Owner Owner's Name
information is required for every Cotuit MA 02635 4/6/12 E `
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
At time of inspection cesspools appeared to be in�working.order, tees present.no sign of deteration,or
back-up.
Privy(locate on site plan): ; • ,'
Materials of construction:
Dimensions -
Depth of solids
E.
rComments (note condition of soil, signs'of hydraulic failure, level of ponding, condition of vegetation,
etc.): . ..
4.
e
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
a
Title 5 Official Inspection Form g
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
{
91 Nickerson Rd i
Property Address
Arthur Hughes
- Owner Owner's Name
information is required for every Cotuit MA 0205 4/6/12
page. Cityrrown State Zip Code Date of Inspection !
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system;.including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately x
'
tt®O
Q - all�'
i
t5ins•11/10 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
91 Nickerson Rd
Property Address t
Arthur Hughes `
Owner
n . .•. Owner's Name
information is
required for every 'Cotuit MA 02635 4/6/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) .'
Site°Exam: -
®, Check Slope .
® Surface water,,
Check cellar,
® Shallow wells _ F
� . >15;
'Estimated depth to high ground water: feet
�.
Please indicate all methods used to determine the high ground water elevation:
❑ �-, Obtained from system design plans on record
• If checked, date of design,plan reviewed: Date
.Observed site (abutting-property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked withlocal excavators, installers-(attach documentation)
❑ - Accessed•USGS database-explain: - ..
You must describe how you established the high groundwater elevation:
w rear of dwelling drops off,
• •
1 �
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 ro. 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 91 Nickerson Rd
Property Address r x
Arthur Hughes
Owner Owner's Name
information is required for every Cotuit 4 MA' ' 02635 4/6/12 t
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D,or E checked
4 ® 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
. .: i s
t5ins•11/10 _Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
LOCAT � S� AGE PERMIT N0.
qN/,
VILLAGE
INSTA LLER'S NAME i ADDRESS
BUILDER LR _�"
DATE PERMIT ISSUED 9_`�_ 75,
DAT E COMPLIANCE ISSUED
o/
PM
v"
fN
r
r =
No(Vl' s-.V-.. FimALO.o..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................''fA1 nW .....OF.....Ba
Applira#ion for Disposal Works Tonstrnrtiun Vrrmit
Application is hereby-made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
X 91 Nickerson Road �►� �� -
--•-....... -.. . ................................ ........................ ......-•--- ----••----------•---.........._...--------------•--......---•--•-•-•
Location-Address or Lot No.
Arthur Hughes.....:...-•--•.............•-•••-•--......._. ......Cotuit
- . - ..._ ..... - ....... ....................
Owner Address
a Joseph P. Macomber _& Son Inc, Centerville
Installer Address
PQ
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( )
�+
`k Other—T e of Building No. of persons............................ Showers — Cafeteria
04 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........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.........._......... Depth to ground-water........................
----------------------------------------
__.........
•--------------
....... ________----------•---------.........----------------------
-.........
ODescription of Soil.....S.a'ad...c�_.grave_l...............•--•-•--•----.._..-------------•----.....----------•-------•-------•-----......--•--•---------...---.....----•
x
V -••---•--•---•-...-----•--•--•----------------------------••-•-..._._...---•---------...-•--...•••-----......--------- .........................................
W ...
U Nature of Repairs or Alterations—Answer when applicable-In.1000---gal ou--p_7.-t______________________________________________
-•--------------------------•--------------•----•-•---------------------------....-••-_.._.__..._...._...__.....---•--------•------•-----•--•-••----•--••••-------•-••-••-•---•--•------•--•............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI:IE 5 of the State Sanitary C —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be i sued by e bid ofjte lth.
. C
r l
Sigd la -------------------------- -�C��................................. .1. .._
® Date
Application Approved BY :-------------------------- -----=-I'-'��._7
- -- ---
Dat
Application Disapproved for the following reasons____________________________________............................................................................
-•--------------•---.......-•-------•----....---....-------------•---•-----•---------•-•--...-------•-------•---------•--•-•--------••-----••---•--------•-------------------------•-----------••-------
Date
1
PermitNo......................................................... Issued_--- - .........................................
�� Date
i
F
No..�)f l... Fzas 5.00...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................Tawn......OF.....Barns.tabs.e..--•.....................................................
Appliration for Disposal Works Tonfitrnr#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
A 91 Nickerson Road �p
................_.....__....................._......_.............._.......................... ......."..C�cl r11......4`............
Location-Address or Lot No.
.....Arthur Hughes.... ................................... ------Cotuit
Owner Address
a Joseph P. Macomber Son Inc . Centerville
.. . ........ .-
Installer Address
Type of Building Size Lot............................Sq. feet
,., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Pa Other fixtures ..............................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W 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. I................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........................
-----------------------------------•----•-------•--•-----....----------..........-..-------------•--------
-----------------
------------
------------
•---
•••••-
ODescription of Soil.....Rand...&..gram.el..............................................................................................................................
x
V .....••---••--•••-•-••-...-•••-•••-••-•.....---••-----------•-••..........................•...................•--•-•-•---.....-••...-•-•------•••---•-••................................-----•--•--..--•-
W
-----------------------------------------------•---------------...----------- ----------------•------------...-------------------------------------••--•--•------.................•------------•--•----
U Nature of Repairs or Alterations—Answer when applicable.InIO00..gallon..pit..............................................
. 1.---•--------- ---------------•------•----------------------------.....------•-••----........----•--------•----------------------------------....._...--------------------------------------..._•--.---•-•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of th'e State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i'sued by the board o Ith.
// r
Si ed .. .1�..r . --.......... = �1 l fit!}�r�0/ /�/��� 1.......
Date
Application Approved By..... Datf
Application Disapproved for the following reasons:..............................................................................................................
............................•---....---------------•-----•--•---•------------------..........--------------------------••-------....__....------........---------------------------------------•-•-----
Permit No. .............................................. Issued..�`_��—7
Date
---Date---- ........................
THE COMMONWEALTH OF MASSACHUSETTS
r-
BOARD OF HEALTH
...................Totyn..........OF.....Barnstable '
........... :.... .................
vyprtif iratr of Tuntpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X)
by Joseph..P,...Macomber. &.Son---Inc .............................• --
Installer
at 9 ••Nickerson...Road� Cotuit.. .....................-•---•-••-••••--•••-••--••........•---•-----------•-----Hu.;hes.......----
has been installed in accordance with the provisions of T P 5 of The State Sanitary Code as described in the
application..for Disposal Works Construction Permit No. : ..-._�c................ dated 1.1..-:-/.�!`�7_y_:;
____................
7 -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 4�
C ..
DATE-----.•--- % ..�1 �? .................................... Inspector........ .... 1......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T'O€ 1......OF........ rnetable
N ~ ... ....................... FEE.. ...o'.�-------•
�.. Disposat Workii Taoniitnulitn ramit
Permission is hereby granted..�� h P. Macomber & Son c .
...•••. .......-•-.•... •-•------------------••-••---••••--••---......•-----.........................
to Construct Y( ) or Repair Road.X) an Individual Sewage Disposal System
at No..9 ,R Gk en... _C.ot�it................... -•--•-......--I hes.._.....---••-
PP p street Date N,
as shown on the application for Disposal Works Construction Per No._ /_/.,_ .._. _ �d.""..�' ............
.............
Board of Health 'r
DATE........ '7��'--•---•--------------------------••--•----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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