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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;
132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection r„
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:out f rms A. General Information
filling out forms �� j a 311
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not REID C. ELLIS
use the return Name of Inspector
key. °
ELLIS BROTHERS CONSTRUCTION
Company Name
23 ENTERPRISE ROAD
Company Address
YARMOUTH PORT MA 02675
City/Town ` State Zip Code
508-362-6237 S 121891
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems.'I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5/(310 CMR 15.000).The system:
LJ Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspector ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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°3113 Title 5 Official fnspection Form_Subsurface Sewage Disposal System•Page 1 of 17
l oyf-d VS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
«... .•'�� 132op Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
— _ _
Prerty Address —---------
Thomas E. Carver
Owner information is Owner's Name
required for every Cotuit MA 02635 04/27/2017
page. City(rown State Zip Code Date of Inspection
B. Certification (Cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
�g❑ I have not foun ny 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:
L
B) System Conditionally Passes: 1�
❑ One or more system components as deE cribed 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 determi ed"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years o d*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or a filtration or tank failure is imminent. System will pass
inspection if the existing tank is replaced wit a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3/13 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
132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operation . System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a br en, settled or uneven distribution box. System will
pass inspection if(with approval of Board of H alth):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below).-
El 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):
Elbroken pipe(s)are replaced ElY ElN ElND (Explain below):
El obstruction is removed ElY ElN
❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evak ation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132-Nickerson Road;Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 - 04/27/2017
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board cf alth (and Public Water Supplier, if any)
determines that the system is functionin in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil a sorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributa y to a surface water supply.
❑ The system has a septic tank and SAS nd the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria_ are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
�/, due to an overloaded or clogged SAS or cesspool
❑ L��/ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
❑ than Y2 day flow
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 132.Nickerson Road, Cotuit,.MA 02635 SYSTEM B--SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ V,4 Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system fails. I have determined that one or more of the above failure
Criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Boa of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"nolurface
to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a drinking water supply
❑ ❑ the system is within 200 feet of a ibutary to a surface drinking water supply
❑ ❑ the,system is located in a nitroge sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone of a public water supply well
If you have answered"yes"to any question in Section 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•3/13 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
132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ 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?
r ❑ 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: Id Al .45 &h It A4- 3 o,tt.
❑ Existing information_ For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
- 132 Nickerson Road, Cotuit, MA 02635°SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. CityT town State Zip Code Date of Inspection
D. System Information
Description: / fl
Number of current residents:
Does residence have a garbage grinder? ❑ Yes tn/No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes � No
information in this report.)
Laundry system inspected? ❑ Yes M/No
Seasonal use? ❑ Yes �/No
Water meter readings, if available(last 2 years usage(gpd)):
Detail: /c_l� j
V�if O�iO 8i ho ' /,/�i � _ 4 �B1�fB•C'�
Sump pump? _ ❑ Yes No
Last date of occupancy:
Date
Commercial/industrial Flow Conditions: A114
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats%persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 syste ? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
- _ 132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page_ Cityrrown state Zip Code Date of Inspection
D. System lWorrmation .(cont.)
Last date of occupancy/use: �`
Date
Other(describe below):
General Information
Pumping Records:
Source of information: � ""�""t
Was system pumped as part of the inspection? ❑ Yes Lf No
If yes, volume pumped: �'4x'v
gallons
t/
How was quantity pumped determined?
d.
Reason for pumping:-
Ty o System:
Septic tank, distribution box, soil absorption system
Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
-- Title 5 official Inspection Form
Y
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w� 132 Nickerson Road, Cotuit,:MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner Owners Name
information is required for every Cotuit MA 02635 04/27/2017
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes L`1 No
Building Sewer(locate on site plan):
Depth below grade:
feet
Mate ial of construction:
` cast iron ❑40 PVC ❑ other(explain):
t
Distance from private water supply well or suction line: -�v feet
Comments(on condition of joints, venting, evidence of leakage,etc.):
Septic Tank(locate on site plan)
Depth below grade:
�N feet
Material of construction:
M/Concrete ❑ metal ❑fiberglass ❑ olye ene ❑other(explain)
,1Iv 10,4
If tank ismI, I st ge:
kA years
Is age onfi ed y a Certificate of Compliance?(att h a copy of ce ificate) �] es ❑ No
Dimensions:
Sludge depth: �
t5ins-3/13 Title 5 Official inspedon Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) '3
Distance from top of sludge to bottom of outlet tee or baffle
v
Scum thickness
O
Distance from top of scum to top of outlet tee or baffle
(J
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels-ass related to outlet invert, evidence of leakage, etc11
.):
v� d 1"✓Ie CIF d
s 4 7
Gj sm � WrA-
Grease Trap(locate on site plan): 14111
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fibergl ss ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffl
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
l5ins•3113 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�.., 132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E_ Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page_ Cityrrown state Zip Code Date of Inspection
D. System Information (cont.) �
Comments(on pumping recommendations, inlet nd outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence 01
leakage, etc.):
Tight or Holding Tank(tank must be pumped attI of inspection) (locate on site
plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fib rglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ -Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(requi d). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
i
Commonwealth of Massachusetts
v
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�.. 132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address — -------
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 " 04/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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 sit�plan)��: A/
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes- ❑ No*
Comments(note condition of pump chamber, ndition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont
��v '4��p fro �;It,
Ty613pe:
leaching pits_ number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.
00A)di AJ"T_ !Dil &)AS
Air
Cesspools (cesspool must be pumped as of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
h
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w• 5•''Y 132 Nickerson Road, Cotu.it,.MA 02635 SYSTEM 13-SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydrauli failure, level of ondin condition of vegetation,
P g,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydr ulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
*. 132 Nickerson Road, Cotuit, MA 0263 SYSTEM.B SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
N 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
wh r`e public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
El drawing attached separately
. �Ro
;&
1
Al
Wgr,
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
W 132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Check Slope
dsurface water AP?J---
0 Check cellar 7 G n � &I
❑ Shallow wells mC��
�V 6
Estimated depth to high ground water: feet
Please Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: V
�40
/I- C/ -
721 2R
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM B-SIDE YARD
Property Address
Thomas E. Carver
Owner information is Ownees Name
required for every Cotuit MA 02635 04/27/2017
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Inspection Summary:A, B, C, D, or E checked
Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
d
ystem Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
vndy. i ►. to I ► 0:1 IHm NO. 0/4 F. I
CERTIFICATE OF ANALYSIS page: 1 of 1
Barnstable County Health Laboratory (M-MA009)
, Sb^ Report Prepared For: Report Dated: 3H8/2017
Reid C.Ellis
Ellis Brothers Construction Order No.: G1799212
23 Enterprise Road,P 0 Box 59
Yarmouthport, MA 02676
Laboratory 1D#! 1799212-01 Description: Water-Rrinking Water
Sample& sample Location: 132,Nickerson Rd.Cotuit,MA Coltected: 04/26/2017
Collected by. Recehred: 04/28/2017
Routine
ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOW
Nitrate as Nitrogen 1,0 mg1C 0.10 10 EPA 300A LAP 412WO17
Copper 0.030 mgfL 0.10 1.3 EPA 200.7 VZ 5/7/2017
Iron 01010 mg1L 0.10 0.3 EPA 200.7 Vz 5/7/2017
pH 5.9 PH AT 25C PIA 6.5-e.5 SM 45WH-B DCB 4/28/2017
Sodium 1.0 mg1L 0.10 20 EPA 200.7 Vz 5/7/2017
Total Cofiform Absent P/A 0 0 SM 9223 RG 4/2812017
Conductance 100 Umohs/cm 2.0 EPA 120.1 DCs 4/28/2017
Watersample meets the recommended limits for drinking waterof a//the above tested parameters.
Attached please find the laboratory certlfled parameter 116t. Approved By:
(Lab DirWar)
ND=None Detected RL = Reporting Umit MCL Mextmum Contaminant Level
3195 Main Street, P0.Box 427, Barnstable, MA 02630 Ph:508-375-6605
IfIdY, I /. Lull o.«nm No. 46/4 P.
CERTIFICATE OF ANALYSIS
4
Barnstable County Health Laboratory (M-MA009)
�CIi�IS
Rerlplent: Reld C.Ellis Matrix: Water-Drinldng Water
Ellis Brothers Construction Sampled: 04/28/2017 10:00
23 Enterprise Road,P 0 Box 59 Recelved: 04/28/2017 14:48
YaM=thport, MA 02675 CNleCtion Address: 132 Nickerson Rd.C*fit,MA.
Order#: G1799212 Semple Location:
Lab 10. 1799212-01 Description Lab Analysis
Sample S. Date Analyzed: 4/28/7017 0 14.40
Method-. analyst: yn EPA 524.2 Dilution Factor. 1
Comment: Water sample meets the recommended limits for drinking water of an the above tested parameters.
EPA 524.2- Vv/alb7e ftonjrs by GC/MS
Parameter WWI � MDL Result MCL �L
ug/L ug/L ug/L Vds-1,2-Dkhlco)noet1hene
arameter ug/L ug�L ug/L
Dlchlor0dlfluoromethane ND 0.50 vforrn ND e0 os0
Chtaromethane NO 0.50 ND 70 0 50
Vinyl chloride ND 2.0 050 ,3-DicMorapropene NO OSD
Bromomethane ND 0.50 ibromocrloramethane ND o.so
1,1,1,2 Tetrachlomethane ND 0.50 Dlbtnmomethane ND 0.50
1,1,1Trichlomethane ND 200 0.50 Ethylbenzene ND 700 0.50
1,1,Z,2-Tetradhlomethane ND 0.50 Hexachlorobutadlene ND 0.50
1,1,2-Trichloroethane NO 5.0 0.50 Lsopropylbenzene ND 0.50
1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0.50
1,1-01chloroethene ND 7.0 0.50 Methyl-tembutyl ether ND 0.50
1,1-Dichlonopropene ND 0-50 Naphthalene ND 0.50
1,2,3-T6rhlorobenzene ND 0.50 n-BubAbenzene- ND 0.50
1,2,3-Tridhloropropane ND 0.50 n-Propylbenzene ND 0.50
1,2,4-Trichlombenzene ND 70 0.50 Hsppmpyltoluene ND 0.50
1,2,+TNmethylbenzene ND 0-50 sec-Butylbenzene ND 0.50
1,2-Dlbromo-3-dilorapropane ND 0.50 Styrem ND 10D 0.50
1,2-Dibromoethane(mB) ND o.so tert-Butylbenzene ND o.so
1,2-Dichlorotwzene ND 600 CAD J Tetrachloroethene ND 5.0 o.so
I,2-1)lchlaroe0lane s.0 o 1 ND 000 0.5o
12-Dichlompropane ND 0.50
Total x1'ienes ND 10000 0.so
1,3,5-Trimethylbenzene ND oso cis 1,2-Dichloroethene ND 10 0so
1,3-Dichlarobenzene ND 0.50 trans 1,3-Dichlordpropene ND o.50
1,3-Dichloropropane ND 0.50 ric umethene ND 5.0 0.50
1;4-Dichlarobenzene ND 5.0 0.5o rlcdorofluoromethane ND 0.50
2,2-Dichloropropane ND 0.50 Surrogates %Recovered QC Limits(%)
2-Chlorotoluene ND U0
4-Chlorotoluene ND 0.50 -Bromofluorobenzene 880/0 70 130.
Benzene ND 5.0 0.50 12-DicNorobenzene-d4 1050/0 70 1 130
Bromobenzene ND 0.50
Bromochloromethane ND 0.50
Bromodlchlommethane ND 0.50
Bromoform ND 0.50
Carbon tet►'achlonde ND 5.0 0.30
Chloroberuene ND too 0.5o
Chloroethane ND 0.5o
_ r
Attached please find the laboratory certified parameter list- Approved By: r
(Lab Director) - `
ND=None Detested RL = Reporling Limit MCL=Maxim on minant Level,
3196 Main Street, PO.Box 427, Barnstable, MA 02630 Ph:608 37"605 Page 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments qq
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A -
Property Address KI
Thomas E. Carvera
Owner Owner's Name . ^
information is required for every Cotuit MA 02635 04/27/2017
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.
Important:When filling out forms A. General Information �I
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not REID C. ELLIS
use the return Name of Inspector
key.
ELLIS BROTHERS CONSTRUCTION
Company Name
23 ENTERPRISE ROAD
Company Address
YARMOUTH PORT MA 02675
City/Town State Zip Code
508-362-6237 S121891
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(3 0 CMR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
e � /
Inspector's Sig6ature r 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.
t5'ms•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1Iof�17
Commonwealth of Massachusetts
h =i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver `
Owner Owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. City(rown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
I have not foundrnyf r
information which Indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes: /�✓ j
❑ One or more system components as des 'bed 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 of , 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 complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it iE structurally sound
, not leaking and if a Certificate of
Compliance indicating that the tank is less that 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
1
t5ins•3113 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
n ry is
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operation I. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation'of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of ealth):
❑ 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):
i�
1
i
yi
❑ 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):
I
C) Further Evaluation is Required by the and of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
*.. 132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Boa d o Health(and Public Water Supplier, if any)
determines that the system is functio ing in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and sc it 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 S S 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 anal,Fsis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the p esence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no othe failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available.volume is less
than Y day flow
t5ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017 .page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No -
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
• of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Bo d of Health to determine what will be
necessary to correct the failure. 0
E) Large Systems:.To be considered a large system he system must serve a facility with a .
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either" " I
9 Y � Y yes or n to each of the following, in addition to the �
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection
El ❑ Area—IWPA)or a mapped Zon ll 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 syst m owner should contact the appropriate
regional office of the Department.
t5ins•3l13 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
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
R
Ys No e
❑ 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)
; El/1 Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
ElWere all system components,4�ding 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.
o Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions: 113
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
t5ins•3/13 Title 5 octal Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. Citylrown State Zip Code Date of Inspection
D. System Information
s v
Description: e
Number of current residents:
Does residence have a garbage grinder? ❑ Yes - No
Is laundry on a separate sewage system?(Include laundry system inspection El Yes information in this report.)
Laundry system inspected? . ❑ Yes yNo
Seasonal use? ❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Detail
le ZZ/ 1;14 A/
N- 4
Sump pump? ❑ Yes No
Last date of occupancy: �� �� ; j 6rsr� Date�nZ1r �Commercial/Industrial Flow Conditions:
6
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of.design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 syst m? ❑ Yes ❑ No
Water meter readings, if available:
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� 132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: "��
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? M/Yes ❑ No
If yes, volume pumped:
gallons �
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
t Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�... 132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is COtUIt
required for every MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
gv: A, /A,,
Were sewage odors detected when arriving at the site? ❑ Yes,VNo
Building Sewer(locate on site plan):
Depth below grade:
f et
Material of construction:
/cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: 115./
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t /14L / ! ice! ` C',
Septic Tank(locate on site plan): / In
Depth below grade:
feet
Mat 'al of construction:
concrete metal ❑fiberglass polyethylene ❑ other(explain)
-aa, A&i
If tank is me�I, li age:
,�/ years
l/v Is age nfi d by a Certificate of Compliance?(attach copy of c ficate) ❑ Yes ❑ o
Dimensions: ZZk
Sludge depth:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
O
Scum thickness
O
Distance from top of scum to top of outlet tee or baffle
O
Distance.from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liqui levels as related r
utlet i vert, evidence of leakage etc.):
7L �I1WWAAvA [4-7 (SAS A
� � 6
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tei or baffle
Distance from bottom of scum to bottom of c utlet tee or baffle
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal
P g pawl System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address "
Thomas E. Carver "Y
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
N i�.
Comments(on pumping recommendations, in 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 pum ed at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float s itches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
.T
.. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V0'e 132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate o 1 e plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence 4solids carryover, any
evidence of leakage into or out of box, etc.):
Azz
l�l
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, con ition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) 1 00 o 7411011
Type: � � .,a its✓� -a���
leachingits n `
p umber:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, e -j � � _ lO
A NJ 3 �
A,aw
Cesspools (cesspool must be pumped as pa, 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
l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
1 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
.Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic/2ure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site
�
plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydrau is failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
--- v Title 5 Official Inspection Form
r< Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 0263 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
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
/V 7hhand-sketch
re public water supply enters the building. Check one of the boxes below:
in the area below
El drawing attached separately s''V
�l
r `
14 r
Yl l- 3
AW
Ye
rj7� 7 0 ! (�✓�
;�P3 . 3I
t5ins•W13 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
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 04/27/2017
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope 'Z�w ell
❑ Surface water AAe—
❑ Check cellar 4�� e6zol �ILZ-L
❑ Shallow wells
000
l
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 with local excavators, installers-(attach documentation)
Accessed USGS database-explain; �
You must descri a how you established the high ground water eleva Ion: L
u
5i 6,
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3r13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System.Page 16 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 SYSTEM A
Property Address,
Thomas E. Carver
Owner Owner's Name
information is required for every Cotuit MA 02635 04/27/2017
page_ Cityrrown State Zip Code Date of Inspection
E. 71;1spection
ort Completeness Checklist
Summary: A, B, C, D, or E checked
I spection Summary D (System Failure Criteria Applicable to All Systems)completed
S stem Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
n.u,. I I. LV I I V L ItM.
F CERTIFICATE OF ANALYSIS Page: 1 of 1
Barnstable County health Laboratory (IV-MA►009)
y
Report Prepared For: Report Dated: 5/1012017
Reid C.Ellis
Ellis Brothers Construction Order No.: G1799212
23 Enterprise Road, P 0 Box 59
Yarmouthport, MA 02676
Laboratory to m 1799212-01 aescription: Water-Drinking Water
Sample#: . • Sample Location: 132 Nickerson Rd.Cotuit,MA Collected; 04/28/2017
Collected by: Received: 04/28/2017
Routine
ITEM RESULT UNITS RL MCL METHOD# 'ANALYST TESTED NOTE
Nitrate as Nitrogen 1.0 mg/L 0.10 10 EPA 300.0 LAP 4/29/2017
Copper 0.030 mglL 0.10 1.3 EPA 200.7 VZ 5f112017
Iron 0.010 mg/L 0.10 0.3 EPA200.7 VZ 5/7/2017
pH 5,9 PH AT 25C NA 6.5-8.5 5M 4500-H-13 DCB 4/28/2017
Sodium 1.0 mg1L 0.10 20 EPA 200.7 VZ 5/7/2017
Total Co(iform Absent PIA 0 0 sM 9223 RG 4/2812017
Conductance 100 umohs/cm 2.0 EPA 120.1 DC9 4/28/2017
Water sample meets the recommended llmits for drinking water of all the above tested parameters.
Attached please find the laboratory certified parameter list. Approved Bel: _�.•�z
(Lab Director)
No=None Detected RL = Reportrhg Limit MCL=Maximum Contaminant Level
3195 Main Street, PO.Box 427, Barnstable, MA 02630 Ph:508-375-6605
may. I P. [U I t 0;LLMIVI No, 40/4 f. z
A CERTIFICATE OF ANALYSIS
' Barnstable County Health Laboratory (M-MA009)
d
Recipient: Reld C.Ellis Matrix: Water-Drinking Water
Ellis Brothers Construction Sampled: 04/28/2017 10:00
23 Enterprise Road,P 0 Box 59 Received: 04/28/2017 14.48
Yarmouthport, MA 02675 Collection Address: 132 Nidterson Rd.Calif t,MA
Order#: G1799212 Sample Location:
Lab 10; 1799212-01 Description: Lab Analysis
Date Analyzed: 4/28/2017 @ 14:40
Sample a: Analyst: yn
Method; EPA 524.2 D➢ludon Factor. i
Comment: Water sample meets the recommended limits For drinking water of all the above Nested parameters.
EPA 524.2- Volatile®rganlcs 6'iy OCIINS
18eault JJQL ➢ QL Result HL
Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L
Dichlorodllluoromethane ND 0.50 Chloroform ND 80 0.50
Chioromethane ND 0.50 ds-1,2-Dichloroethene ND 70 oso
Vinyl chloride ND 2.0 0.50 ds-1,3-Dichloropropene ND oso
Bromomethane ND 0.50 Dibromachloramethane ND oso
1,1,1,2-Tetraftruethane ND 0.50 Dibromomethane ND 0.50
1,1,1-Tr1chloroethane ND 200 0.50 Ethylbenzene ND 700 0.50
1,1,2 2-Tetracbioroethane ND 0.50 Hexachlorobutadlene ND 0.50
1,1,2 Trichloroethane ND 5.0 0.50 [sopropylbenzene ND 0.50
1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0.50
1,1-Dichloroethene ND 7.0 0.50 Methyl-tent:-butyl ether ND 0.50
I,I-Dichloropropane ND 0.50 Naphthalene ND 0.50
1,2,3-Trichlombenzene ND O.SD n-Butylbenzene• ND 0.50
1,2,3-Trichloropmpane ND 0.50 n-Propylbenzene ND 0.50
1,2,4-TricHorobenzene ND 70 o.so p-Isopropyltaluene ND 0.50
1,2,4-Trimrthy1benzene ND oso sec-Bufylbenzene ND 0.50
1,2-Dibromo-3-chlorapropane ND 0.50 Styrene ND too 0.50
1,2-Dibromoethane(EDB) ND 0.50 tert-futylbenzene ND o.so
1,2-Dichlorobenzene ND 600 o.so Tetrachloroethenc ND 5.0 0.5d
1,2-1)lchloroethane ND 5.0 0.50 Toluene ND 1090 o.5o
1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50
1,3,5-Trimethylbenzene ND 0.50 trans-1,2-Dichloroethene ND 100 oso
1,3-Dichiorobenzene _ ND 0.50 trans-1,3-Dichloropropene ND 0.50
1,3-Dichloropropane ND 0.50 Trichlaroethene ND 5.0 0.50
1,4=Dirhiorobenzene ND 5.0 0.5o r➢dllarnFluoromethane ND 0.50
2,2-Dichloropropane ND 0.50 Surrogate cbRecovered QC I1mlt5(%)
2-Chlorotoluene ND 0.50 -Bromotluarobenzene 880/a 70 130
4 Chlorototuene ND 0.50 1 2-DicNombenzene-d4 1650/0 70 130
Benzene ND 5.0 0.50
Bromobenzene ND 0.50
Bromochioromethane ND 0.0
BromodicNoromethane ND 0.50
Bromotorm ND 0.50
Carbon tetrachloride ND 5.0 0.50
Chtorobenzene ND 100 0.50
Chloroethane ND 0.50
Attached please find the laboratory certified parameter list_ Approved
(Lab D(rector)
ND=None Detected RL = Reporting Vmit MCL=Max�Iclrnilnant Lez,
3195 Main Street, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1
McKean, Thomas
From: McKean, Thomas
Sent: Friday, January 17, 2014 11:23 AM
To: Dabkowski, Cindy
Subject: 132 Nickerson Road, Cotuit/Septic Questionnaire-APPROVED
The Health Division has no objections for approval of the amnesty apartment at 132 Nickerson Road, Cotuit. A floor plan
was submitted showing a total of three bedrooms. The current septic system was designed and constructed for three
bedrooms.
Therefore, this Division has no objections to this proposal for three (3) bedrooms maximum at this property.
i
1
Town of Barnstable Health Inspector
g HE Regulatory Services Office Hours'
Thomas F.Geiler,Director 3:30-4:30
S`ABIM Public Health Division
MASS.
s
Thomas McKean Director
a�E®may A
x 200 Main Street,Hyannis,MA 02601
Office``508-862-4644 _ Fax. 508-790-6304
- AMNESTY PROGRAM APPLICANT ",SEPTIC QUESTIONNAIRE,
Date: September 4,2013
°
1. General Information: Size of Property.75 acre
Address:-132-Ni6kerson Rd-Cotuit MA 02635 Map 018 Parcel 127
Name:Thomas E. Carver Phone#: 508-428-9658
2a. How many bedrooms exist at.your property now. 3
v
2b. Are you planning to add any bedrooms?NO If yes,'how many?•40
2c." How many bedrooms'total are proposed°at this property(including the amnesty unit)?3 (2 main house 1 apartment
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed amnesty,apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? NO
if the dwelling is"connected,to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is OUTSIDE, a Saltwater Estuary Protection Zone? —t
5 . Location of dwelling is OUTSIDE a Zone of Contribution.to public supply wells?
6. Is the dwelling connected to'an PUBLIC WATER?
7. Is a disposal works construction permit on.file? ,, YES or NO
8. If yes,how many bedrooms.were approved according to this`permit?` Bedrooms. -..
9. Were any building permits obtained for construction of additional bedrooms? YES or NO
_ .a
10. Is there an engineered_septic system plan on file at the Health Division? ' YES or NO
11, Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
---------------------------- ---- -----------------------------------------------
FOR OFFICE USE ONLY
The Public Health Division has no'objection to'
bedrooms at this property.
Special Conditions:
- F
Signed: Date: l
i
3.
03/18/2002 15:51 15084281211 THE PT CENTER PAGE 01
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X TOWN OF BARNSTAB(
LOCATION_)3?- SEWAGE # Y 2 m 39
J
VILLAGE co 0c
ASSESSORS MAP & LOTS , 7
INSTALLER'S NAME & PHONE NO.,
SEPTIC TANK CAPACITY ,
LEACHING FACILITY:(type),.: (size) O
NO. OF BEDROOMS PRIXATE WELL OR PUBLIC WAT '
BUILDER OR OWNER l oy �' �u d0,�
T _
DATE PERMIT ISSUED: „ _ a F ^7�..
DATE COMPLIANCE ISSUED: 7_�
VARIANCE GRANTED: Yes No ;
r
4-
S ..
THE COMMONWEALTH OF MASSACHUSETTS
6' BOARD OF HEALTH
TOWN OF BARNSTABLr-'
x#�firate. of Tompltttnre.
THUS S TOr.CERTIFY, -Atthe Individual S wa e Disposal System constructed ( ) or Repaired
y .....
( �)
b �............S. Cti�' ,
..... - __.. t . ...
. ............... ...................................................................................................:..........................................
has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code :is described in
the application for Disposal Works Construction Permit No. .....��40 ..g'...,.... dated ....... ".... .........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE l
.................................... Inspector................ : �Y..........:...................................................
ELLIS -.' BR0S . C 0 N S T CO .
T,p.•r"'� 'oi'v� SEWAGE PERMIT NO . JZ. L-3�-
c/
OWNER NAME r� C`r=1(?v:4�
LOCATION t3Z_ wicks nary 2otkp
PERMIT DATE ISSUED COMPLIANCE ISSUEQi.
BUILDERS NAME ` 4Flu
WATER TABLE
FINAL INSPECTION 'BY : DATE ij ���,.
NEW = REPAIR
DRAW SKETCH OF COMPLETED SYSTEM WITH DIMENSIONS ON BA
L3 Ch
' � .Commonwealth of Massachusetts
e ' Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM ; 132 Nickerson Road, Cotuit, MA 02635
Property Address ,
Thomas E. Carver 5
Owner, .. Owner's Name
information is Cotuit MA, 02635 _02/12/2014 `
required for every '
page. City/Town State Zip Code Date of Inspection
'Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. - Inspector:
key to move your
cursor-do not - REID C. ELLIS _ J I—f
��
use the return Name of Inspector
y
ELLIS BROTHERS CONSTRUCTION
�I Company Name ..,
23 ENTERPRISE ROAD -
Company Address
• YARMOUTH PORT MA 02675
City/Town State Zip Code
508-362-6237 S12.1891
Telephone Number f License Number
B..Certification
y I certify that I have personally inspected the sewage disposal system at this adds and tha"dhe J
information reported below is true, accurate and complete as of the time of the Inspection-Tlie inspection
was performed based on my training and experience in the proper function and mbintenance of on site
sewage disposal systems. i am a DEP approved system,inspector pursuant toSection 15.340 of
Title 5(310 CMR 15.000).The system:. `
dO/Passes ,' ❑ Conditionally Passes ❑ Fails
Needs Further Evaluation by the Local Approving Authority
Ins ector's signature 3' , 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 flowof 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•3/13 Title 5 OjInspr.rrr. surface Sewage Disposal System-Page 1 of 17
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1 u Commonwealth of Massachusetts a -
Title 5 Official Inspection LA
p Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635
Property Address
Thomas E. Carver
Owner Owners Name .
information is
required for every Cotuit MA 02635 02/1.2/2014
page. City/Town State . Zi Cdde
p. Date of Inspection
B.=Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria describ
ed
in 310 CMR 1 .3 ed
03 or in 310_ CM 5.304 exist. Any failure criteria not eval ated
in ` .are
di ca r� _ted bel /dim ��..w e
r.
Comments:. ��. — = mot
,1 7
e 1067 ✓
f ,y
B) System Conditionally Passes: a
One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon com letion of the replacement or re
pair,e air as
the P approved b
Board of PP
• Health, will pass. . . . � y
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The setank
tic -ism Pmetal and over 2 0 years old r the septic tank(whether metal or not) is structeirall unsound, exhibits substantial infiltration y
iltra_ tion or exfiltr tion or tank failure ,���_ allure is imminent. System will
II� inspection if the existing tank is're laced with a c ! y I I pass
Health. P mplymg septilc tank as approved by the Board bf
*A metal septic tank will pass inspection if i '
p t Is st ucturally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 2 years old is available.
❑ N a
❑. Y �_ ❑ ND(Explain bel
t5ins•3/13 I
Title 5 Official InspectionForm:Subsurface Sewage Disposal System•Page 2 of 17
d
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635
Property Address
Thomas E. Carver 5
Owner Owners Name
information is '
required forevery Cotuit ' 'MA 02635 02/12/2014
page. City/Town State ZipCode
Date of Inspection
B. Certification_(Cont.)
❑ Pump Chamber pumps/alarms n7operatio al.System will pass with Board of Health approval if
Pumps/alarms are repaired.
B) System Conditionally Passes{cont.)-
El Observation of sewage backup or break ou or high staticjwater level in the distribution box due
to broken or obstructed pipe(s)or due to a I roken, settled or uneven distribution box. System will
r pass inspection if(with approval of Board o Health):
broken pipe(s)are replaced -_, ❑ Y- I❑�N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y, ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replac d ❑ Y.. i❑ N ❑ ND(Explain below):
..
• 1. r .. � :.
❑ The system required pumping more than 4 imes a year due to broken or obstructed . The
i e s system will pass inspection if with approvalp p ( )( of the:Board of
broken pipe(s)are replaced ❑ Y 0 N
. � ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
-------------
C) Further Evaluation is Required by the Board of Health.
❑ Conditions exist which require further evaluation by the Board of Health in order
the system is failing to protect public health safety or-the environment. to determine If
a 1.. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet o ^a surface water
❑ Cesspool or privy is within'50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13-
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 ,
Property Address
Thomas E. Carver
Owner Owner's Name } I
information is 1
required for every Cotuit MA 026315 02/12/2014
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.) i
2. System will fail unless the Board of He th (and Public Water Supplier, if any)
determines that the system is functioning a manner that protects the public health,
safety and environment:
El The system has a septic tank and soil ab_ rption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary o-a.surface water supply.
The system has a septic tank and SAS an J the SAS is within a Zone 1 of a public water
supply. ;
❑ The system has a septic tank and SAS ar d th
".supply well. e SAS is within 50 feet of a private water
El The system has a septic tank and SAS and th SAS is les1s 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; r erformed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presen a of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failui a criteria are:triggered.A copy of the analysis must
be attached to this form.
3. Other:. t
-
j.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following f®r all inspections:
Yes No
❑ Ztl Backup of sewage into facility or system component due to overloaded-or
clogged SAS or cesspool
OR
❑ M Discharge or ponding of effluent to the surface of the ground or surface waters
el/ due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ � liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t5ins-3f13
.Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts I
- v Title 5 Official Ins ection Form
Subsurface Sewage Disposal System Form-Not for Volunta { Assess
ments
132 Nickerson Road, Cotuit, MA 02635
Property Address --
Thomas E. Carver
Owner Owner's Name ,
infor
mation
ni .is
required for every Cotuit . N MA 02635
02/12/2014
page. CitylTown ... � State Zi Code
-----------------
p Date of Inspection
B: .Certification (cont.)
Yes. No r
_ ❑, � ' Required pumping more than 4 times'in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: I
❑ � 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 supplyor
tributary to a surface water supply. `
El- Any portion of a cesspool or privy is within a Zone 1 of a public well:
❑ ids 1 An 1.
y 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 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
0 �✓ The system is a'cesspool serving a facility with a design flow of 2000gpd-
101,000gpd.
El The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The.
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system a system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes° r"no"to each of the following, in addition to-the
questions•in Section D.
`Yes. No
- ❑ ❑ the system is within 400 fe t of a surface drinking water supply
❑ ,; the system is within 200 fe t of a tributary to a surface drinking water supply
E] the system is'located in a n trogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Se tion E the Sys is considered a significant threat,
or answered"yes"r in Section D above the large s stem has failed. The owner or operator of any large
system considered a significant threat under Sec ion E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.-Th system owne I should contact the appropriate
regional office of the Department.`
i
t5ins•3113 1
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
�. Commonwealth of Massachusetts ` _
y. Title 5 Official Inspection' Form:
i;
u Subsurface Sewage Disposal System Form-Not for Voluntary`Assessments .
132 Nickerson Road, Cotuit, MA 02635
Property Address
Thomas E. Carver
Owner information is ,' Owner's Name• {{
required for ever
y
C 0 tUlt •
I
MA ,
02635 02/12/2 014
page: City/Towri State Zip Code Date of Inspection .
C. Checklist
Check if the following have been done. You must indicate"yes"or"no,,as to each of the following:
•Yes No
❑ Pumping information was,provided b th
P y owner, occupant, or Board of Health
❑ 61 Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two weekperiod?
Have large volumes of water 9 been introduced
- � t oh t 0 � e system recently or as part-of
this inspection?
' Were as built plans of the system obtaine�l and examined? (If they were not
_ available note as N/A) 1
p
* 1 Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break 6 ut?
❑ Were all system components;eRcluding_the SAS, located on site?
�� ❑ Were the septic tank manholes uncovere I, 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?
iv =E Was the facility owner(and occupants if di erent 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
r been determined based on:
LpJ ❑ - Existing information. For example, a plan at the Board of Health.
o
: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)1
D. System Information +
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15:203 (for example: 110 gpd x#of bedrooms):
I ,, f � ` 4 ' � - .- ` , !'. • .. it
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
}
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' - a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635
Property Address
Thomas E. Carver
Owner Owner's Name
information is r
required for every Cotuit, -MA 02635 02/12/2014
page. Citylrown State Zip Code Date of inspection
D.,System Information
Description:
• Number of current residents: • 1 -
Does residence have a garbage grinder? El Yes ±VNo
Is laundry on a separate sewage system?(Include laundry system inspection /
information in this report.) ,,_,
' w ❑ Yes L� No
Laundry system inspected? f ❑ Yes No
Seasonal use? ❑ Yes I"J No
Water meter readings, if available.(last 2 years usage(gpd)): i
• Detail:
Sump pump?
❑ Yes No
Last date of occupancy: • A15 —AP-—Al
Date
Commercial/Industrial Flow Conditions:-
Type of Establishment: 1
Design flow(based on 310 CMR 15.204,
i 3), Gallons per day Y(9Pd)
Basis of design flow(seats/persons/sq.ft., etc.): i
i
Grease trap present? i
❑ Yes ❑ No
Industrialwaste holding tank present? ;
❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 Sys em? ❑ Yes ❑ No
,Water meter readings, if available: f
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
ID
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary;Assessments
UP. 132 Nickerson Road, Cotuit, MA 02635
Property Address
'Thomas E. Carver
Owner Owner's Name
information is ('
required for every Cotuit MA 02635 02/12/2014
page. Ciry/Town State, Zip Code Date of inspection
.D. System Information (cost:)
Last date of occupancy/use: ` � �'� "'���1 M , ` Date
Other(describe below):
i
l
General Information
'Pumping Records: .
Source of information:
Was system pumped as part of the inspection? � ElNo
_ 4"-P— Yes
If yes, volume pumped: �`� l ``' t'` �.s ems
gallons
• How was quantity pumped determined? �`'/�
Reason for pumping;
3
Type of ystem:
(� Septic tank, distribution box, soil absorption system
❑ . Single cesspool j
❑ Overflow cesspool -
Privy
❑ Shared system (yes or no) (if yes, attach`prevlous 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 l/A system.by system oo ' tol under contract
' ❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe): 1
t5ins•3113 a
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 17
commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary;Assessments
I
132 Nickerson Road, Cotuit, MA 02635
Property Address
Thomas E. Carver I
Owner Owner's Name
information is !
required for every Cotuit MA 02635 02/12/2014-
page. CltyfTown State Zip Code Date of Inspection
D. System Information (cont.)` j
Approximate age of all components; date installed (if known)andsource of information:
_ x 1Were sewage odors detected when arriving at the site? ❑ Yes �No
Building Sewer(locate on site plan): IDS- 55 01 f,�r A r fw �
Depth below grade:
a i feet
'Material of construction:
1!? cast iron ❑40 PVC ❑ other(explain):
~ Distance from ®�/f water supply well or suction line: •t—` `
et ' .
r Comments(on condition of joints, venting, evidence of leaka , etc.):
r G� J4 zo �.
1
Septic Tank(locate on site plan):
Depth below grade: Z c y: l-J
i .feet
Material of construction:
tom - concrete ❑ metal' - ❑fiberglass
❑ polyethylene ❑other(explain)
i
-l� If.tank is tal, list a rs ea
Is age on firmed y a Certificate of Compliance? (attach a co ' of certificate) 7Yes ❑ o
Dimensions:
Sludge depth:
(r
t5ins•3113 Title 5 offigal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts s
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 -
Property Address i
Thomas E. Carver N
Owner information is Owner's Name
required for every Cotuit MA_, 02635— 02/1 212 0 1 4
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness.
Distance from top of scum to top of outlet tee or baffle `
Distance from'bottom of scum to bottom of outlet tee or baffle
How were.dimensions determined? 1
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
- liquid levels as related to outlet invert, evidence of leakage,etc.):
1 ,
a.
O
�71 �40d oq",
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
1
❑concrete ❑ metal e❑ erglass 0 Polyethylene
❑ other(explain):
Dimensions:
Scum thickness _
Distance from top of scum to top of outlet tee o r baffle '
Distance from bottom of scum to bottom of outl at tee or baffle
Date of last pumping:
I 1 Date
t5ins-3/13 j }
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
v y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 132 Nickerson Road, Cotuit, MA 02635
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 02/12/2014
page. Cltylrown State Zip Code Date of Insp
ection
D. System Information (cont.) r
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):.
f
_ _ 1
Tight or Holding Tank(tank must be pumped/at ttiyme of inspection locate on site Ian
)( plan):
Depth below grade: 1
Material of construction_:
concrete, ❑ metal ❑f berglass P polyethylene
El other(explain):
Dimensions: .
Capacity:
gallons
a Design Flow: j
gallons per day
i
Alarm present: ❑ Yes ❑ No
Alarm level:. Alarm in working order ❑ Yes ❑ No
Date of last pumping: i
Date
Comments(condition of alarm and float switch s, etc.):
Attach copy of current purnping contract
(req Ired). Is copy attached? ❑ Yes ❑ No
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments
M 5 t
132 Nickerson Road, Cotuit, MA 02635
Property Address ; y
Thomas E. Carver
Owner Owner's Name
information is '
required for every Cotuit ' MA 02635 02/12/2014
page: cityfrown state Zip Code _ Date of Inspection
D. System Information (cont.) a
A Distribution Box(if present must be opened)(locate 'n site plan): '
Depth of.li.quid.level above outlet inverts �- �� ✓
Comments(note if box is level and distribution to'outlets equal, any eviden of solids carryover, any
evidenc of leakage into or out of box, etc.):
�--
GS `l ---
rs
CIS
LAD_F� v' AA7
r�6
_ 1
i
Pump Chamber,(locate on site plan):
.Pumps in working order:. / I ❑ Yes ❑ No'
Alarms in working order: El Yes ❑ No'
' Comments(note condition of pump chamber, c ndition of pumps and appurtenances, etc.):
If pumps or alarms are not in workingorder,
, system Is a conditional pass.
e
Soil Absorption System(SAS).(locate on site plan, exx�cavatio� not required):
If SAS not located, explain why: kf�� .Ls�S � `- "�4� �:% ✓
a'
lot
s .�
[Sins•3/13 � ♦. s i
Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System"Form-Not for Voluntary,"Assessments. ,
,y 132 Nickerson Road, Cotuit, MA 02635 j
1y
Property Address
Thomas E. Carver
Owner Owners Name j
information i§ COtUIt i
required for every MA 02635 02/12/2014
page. City/Town State -Zip-Co
de Date of Inspection
D. System Information (cont.)
Type: l
leaching pits number:
❑ leaching chambers _ 'number:
❑ Teaching galleries number:
_ r
leaching trenches. number, length:
YEl - .. leaching fields nu l ber, dimensions:
,
❑. overflow cesspool . number:
innovative/alternative system 1
T e/name of technology.
. YPI
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
veg%ation, tc.): I
I -
•Cesspools (cesspool must be pumped a rt of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert 1
Depth of solids layer
a I
Depth of scum layer
Dimensions of cesspool
Materials of construction
l
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3l13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 13 of 17
s
Commonwealth of Massachusetts
Title 5 Official Inspection• i _ Form •
Subsurface Sewage Disposal System Form-Not for Voluntary)Assessments
E .
132 Nickerson Road, Cotuit, MA 02635
Property Address {
Thomas E. Carver
Owner Owner's Name
information is
required for every ,Cotuit MA 02635 02/12/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.) I
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan): ' I
F I
Materials of construction: {
Dimensions
De•th,of solids
p �
Comments7(note condition of soil, signs,of by aulic failure, level of ponding, condition of vegetation,
etc.): {
t5ins•3/13 Title 5 Official Ins + g Disposal system•Page 14 of 17
pedion Form:Subsurface Sewage Dis sal S
Commonwealth of Massachusetts I f
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments
<'w 132 Nickerson Road, Cotuit, MA 02635 ("
Property Address
Thomas E. Carver
Owner Owner's Name
information is
required for every Cotuit MA 02635 02/12/2014
page. City/Town State Zip Code Date of Inspection
Do System Information (cont.) J
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
whe public water supply enters the building. Check one-of the boxes below:
hand-sketch in the area below
❑ drawing attached separately A/7`
3e �
a .0, . J"
33.
1
V, 31
D, . ,
t5ins•3113 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 Voluntaryl Assessments
132 Nickerson Road, Cotuit, MA 02635
Property Address i
Thomas.E. Carver
Owner
• Owner's N n
ame
information is CotUlt ,
required for every MA 02635 02/12/2014
page. City/Town State - Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water ��"0"1/�.
Check cellar j
❑ Shallow wells " 1
l
Estimated depth to high ground water: ,
feet
Please indicate all methods used to determine the high ground water elevation:
EJ Obtained from system'design plans on record j
If checked, date of design plan reviewed:
Date
❑> Observed site(abutting property/observation hole ithin 150 feet of SAS)
❑ Checked with local Board of,Health-'explain:
. I
❑ Checked with local excavators, installers-(attach documentation)
Accessed USGS database-:explain:
z Ad
You must describe how you established:the high ground Ovate'elevation:
1
xC6,_ d
l
1
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection
1 Form:Subsurface Sewage Disposal System•Page 16 of 17
1
•
..,Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nickerson Road, Cotuit, MA 02635 j
Property Address j
Thomas E. Carver I
Owner Owner's Name
' information is• - '
required for every Cotuit MA 02635 02/12/2014
page., City/Town State Zip Code Date of Inspection
E.,Report Completeness Checklist ;
r
dinspection Summary:A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
s � •
S stem I� y nformatlon—Estimated depth to high groundwater
L""I Sketch of Sewage Disposal System either,drawn on page il 5 or attached in separate file
r t
y
t5ins•3/13 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
U. Lo.•Llll4 0;`IUHIYI I No: 0222 P. 112
.. OF A NA LYS I S Page: 1 of 1
J Barnstable County Health Laboratory (M A009),
Ree®rt Prepared For: Report Dated: 0228/2014
Reid C.Ellis
Ellis Brothers Construction O>rder.No.: G1478705
23 Enterprise Rdad, P O Box 58
Yarmouthport, MA 02475
Laboratery-11)# 1478705-01 '. Description: Water-Drinking Water --
I I
Semple#: Sample Location: 132 Nickerson Rd Cotuit,MA { Collected: 02/1212014
Collected by: Customer 1
{ Received: 02/12/2014
Routine
ITEM RESULT UNITS RL MCL METHOD ANALYST TIESTED NOTE
Nitrate as!Nitrogen 0.12 rng1L 0.010 10- EPA 300.0 LAP 021132014
Copper 0.039 mg/L 0.003 1.3 }PA 200.7 LAP 02/13/2014
Iron 0.030 mg/L _ 0.010 0.3 EPA 200.7 LAP 0211 3/2 0 1 4
pH 5,7 Phi AT 25C NA 6.5-8t5 SM 4500-H-8 DCB 02/122014
Sodium 20 mg/L 110 °20 �PA200.7 LAP 02/13/2014
Total Coliform Absent PIA o ,. o sM 9223 RG 02/122014
Conductance ` 150 umohs/cm 10 EPA 120.1 DCB 021122014
Sodium level is at the maximum contaminant level. Those on a low sodium diet may wish to consult a physician.
Attached please find the laboratory certified parameter list. Approved Gii:
(Lab Manager) I"
n
ND=None Detected RL = Reporting Limit , {. MCL=maximum Contaminant Level
Superior Court House, P®.Box 427; .Barnstable,'MA 02630 Ph,506 375-6605
C-�U. L0.ALUl4 0 gUANI k
ypFnn j No. 0222 P. 212
sCERTIFICATE OF ANALYSIS
�y Barnsta,ble county Health Laboratory (M-MA009)
Recipient: Reld C CIUs Matrix.
Water'prinking Water
Ellis Brothers Construction
Sampled: 02/1212014 12-51
23 Enterprise Road,P O Box 59 Received: d2/12/2014 .15:40
Yarmorithport, MA 02675 Collection Addrass: 1132 Nidcerson Rd.Cotvlt,MA
Order#,. G1478705 Sample tocattione i
Lab ED: 1478705-01 Destrlptlofl: rkt
Sample#: Date Analyzed: 02/14/2014 @ 12:01
Method: EPA•524.2 t , . . Analyst: y;,.
Comment; Sodium level Is at the maximum congminant level. Those on a low sodium diet may wish to consult a physiclan.
SPA 524.2- Volatile Organics!)y-GC/RS
Result NCIL ( _
Parameter MCL MOL
ug/L ' ug/L ug/L Parameter° ug/L ug/L ug(L
prchlorodifluoromethane ND 0.5o Chiorofnrtn � ND 80 aso
Chloromethane NO 0.50 ds-1,2-Dlchloroethene
Vinyl ct•,toride � � - • ND 70 0.50
y ND" z_o 0.50 cis-1,3-Dichloropropane I ND 0.50
Bromomethane ND' 0.50 Dibromochloromethane
1,1,1,2-Tetrachlaroethane - ND a.so
NO 0.50 Dibromomethane j ND 0.50
1,1,1-Trichloroethane , ND 200 0.50 Ethylbenzene NO 700 0.50
1,1,2,2 Tetrad�loroethane ND 0.50 liexadllorobu[adiene_ ( ND o.50
1,I,Z Trichloroethane ND s.o oso Lsoprapylbenzene { M Np o,50
1,1-Dlchloroethane ND 0.50 _ Methylene chloride
{ ND S.0 0.50
1,1 Dichloroethene ND 7.0 0.50. Methyi•tert butyl ether { NO 0,50
1,1-Di - ND M 0.5o Naphthalene - j ND 0.30
1,2,3-Trid�lorabenzene Nt) Oso n Butylbenzene ; NO 0.50
1,2,3-Trichloropropane NO, 0.50 n-Propylbenzene ; ND 0.50
1,2,4-Tr►chlorobenzene ND 70 0 50 p-Isopropyitoluene NO 0.50
1,2,4-Trimethylbenzene ND. 0.50 sec-Butylbenzene i ND 0-s0
1,2-Dlbromo-3-chloropropane NO 0.50 Styrene ND 100 0.50
1,2-olbromoethane(EDB) Nd: o0 art-Butlbzne ND 600 e
Tetrachloroethene 1 ND 5.0 o.5o
1,2-01chloroethane NO 5.0 0.50 Toluene i NO 1000 0.50
1,2-Dlchloropropane ND, Total xylenes ! ND 10000 0.50
1,3,5 Yrimethylbenzene ND 0.50 trans�l,2-Dlchloroethene E ND 100 oso
0-01chiorobenzene ND 0.50 trans-1,3-Dlchloropropene i ND oso
1,3-Dlchloropropane NY 0.50 Trlchioroethene ; ND 5.0 0.50
1,4-Dlchlorobenzene ND . 5.0 0.50 7richtorottuoromethane ND 0so
2,2-Dlchloropropane NO: 0.50
Surrogates %Recovered ecovered 2 Chlorotoluene ND 0.50 QC Limits(%)
4 Chlaratoluene I p-Bromofluorobenzene } 103% 70 130
ND 0.50 12-Dlchlorobenzene-d4 j aS6% YO 130
Benzene - ND 5.0 0.50 •• -•
Bromobenzene ND' 0.50
Bromochioromethane
N)- 0.50
BromOdlchloTomethane ND 0.50 i
Bramoform ND' 0.50 s
Carbon tetrachloride ND' 5.0 0.So -
Chlorobenzene ND 100 o.so
Ch►oroethane NO, 0.50 '
Attached please find the laboratory certified parameter UsL Approved By:
(Lab Director)
ND;;None Detected RL Reporting Limit I MCL=Maximum Conlaminant Level
Sf pedor Court House, 00.Box 427, Barnstable, MA 02630` ph:600-375-6005 page 1 of 1
TOWN OF BARNSTABLE
LOCATION (3� 6ucL Pia 956 SEWAGE #
VILLAGE Co +.uc "~
;ASSESSOR'S MAP & LOT6 0- Va.7
a
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY 1 , 3
LEACHING FACILITY:(type) ."p - - (size) 00
NO. OF BEDROOMS PRIVATE- WELL OR PUB -I _ WAT _R
BUILDER OR OWNER Tory,-, C.AP.0 A,
DATE PERMIT ISSUED: ..
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No r
a
��
d
x
�'r+�c �p���
G� �uS�`i
;,a ,.
�� Vie.
- `.1, - it
''�
�Ry ..
cy
No... �?..�... ./ Ficz............... �
® THE COMMONWEALTH OF MASSACHUSETTS
eAOwnment BOAR® OF HEALTH
,OWN OF BARNSTABLE
Appliratinn fur Di ipw3al Wnrtai Towitrnrtinn prutit
Application is hereby made for a Permit to Construct ( ) or Repair ( n Individual Sewage Disposal
System at,
o anon-:\ddress �sa�j�/��...�CT"" N/l./��. 4.��G!!!-T
/ W----� �-----------•-- -------- ----- ------------------------6-----.._.....---:-------.•--------..... -----.. .---..-----..
Wd
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No, of Bedrooms.................................................................EXpansion Attic ( ) Garbage Grinder ( )
Q, Other—Type 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........................................
0_1 Test Pit No. I................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........................
x •-------------------------•---
ODescription of Soil-------------------------------•--------------•-•---...---------------------------------.-.-.•...---------------------•-----------------•--..........................••-
x
c, ------------- ---
W •---••--------------------------•..........•...---------------....--•---------------------.-....--•----------- � ----------
U Nature of Repairs or Alterations—A we when plic le. :. • ...-......x� L
7 , r
. �� = G
Agreement: �/ S
The undersigned agrees to install the a oredescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
� ..... .' ............
Signed ........ .... �
Dace
Application Approved By ................0 7.......... ........---- .........................--------
Application Disapproved for the following reasons: ........................................................................................................................................
................................................. .................. . ................................ ........... ............... .. .. .....................
Dare
Permit No. </:, ........... ..�a... ..�................ Issued .
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certif rate of Toraylialnce
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
P Y P
Ins�allcr
has been installed in accordance with the provisions of TITLE 5�off The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..... ----- dated ........_.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.._...._------------ �..-.. _cts°... �� .- ... ........... Inspector ``_'y"`` ---- -----------------------------------------.......
U
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.....
��..�::..���g FEE...............:
Permission is hereby granted.----. -5-...�`�,��C :__G' 5_-- �-��
to Construct ( ) or Repair ( an Individual Sewage Di osal Sy, tem
7 /(, ��•�� .w ��.......5 a,''f._.�_. ------------------------------------------•-............
at No.------.... -c �r v v r
Street
as shown on the application for Disposal Works Construction Permit No.?P,-rz3.59.. Dated...........................................
a ----------------------•---------------........---......
Booarrd of Health
CY
DATE............. -1.- .,.. .
FORM 36508 HOBBS R WARREN.INC..PUBLISHERS
yy.Lw,.:;v''..«'4w1,..>.e....isx..-t;x�t.'rc�:i�.,>3r1;.:1."•�r.s-.:',d..�.�.:�...,j.,H:y.:,}�,..a:��,w.....C.c..+..:...s...i�+'a...-Z�.a'St�fi3�1^iaa,ail.-s-« +'e.'e�f•'^�...i"��w.,iilS...��..�uu�-s.J,'.4,.*��r,:t377K.'�.Ax`,`'u[G�K
- A •
NO...f,2-.-!--------� FEE... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF BARNSTABLE
Appliratinn for Ui!3poml Wnrbi Towitrurtinn Frrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( 14/an Individual Sewage Disposal
System at- 4
oration-Address r L.ot Noe�.
/r �_�....//✓:_. �Z�00/7- ---------------- /30� r .��
Otenec Add ass
--------------- G�iIT �1L. --,T
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms.__....._...3_________________________EXpansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures _______________________________ _ _
WDesign Flow.....................:......................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity...._._....gallons Length---------------- Width________________ Diameter................ Depth................
Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No_____________________ Diameter....-._--_._________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.................................
--••--------=-----••-------•-•----•--• Date........................................
a 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........................
9 --------•--------------------•-----••--•••------•-•------••--•-•--••-•-••••••••-••-•......---•-..............-•---••--•----•................._......--•---...
ODescription of Soil.......................-..................................................-...------..------------•-•-----•-•-•--••-•-----•-•._.......•--................_-----.-----
x
U
W ----••----------------------------------------------------------------------------- -------•-------•------------------.-------......--------------------------- ....................................
VNature of Repairs or Alterations—Answer when applicable._ �_s_ ._G �......... .........../
Agreement: /
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed � f G" 1 �12i
Dace `
Application Approved By ............ P� ..... ..e�- -.4.�_ ............. - .................................. ... - -1D- ....�..SS..-.-.�f��
Application Disapproved for the following reasons: . .... .............. --.............................................................fe..................
.. ........... ... .................................... . ................. .....................................
. Date
PermitNo. ...... .e�.1...�� ...-.:.��... ...��................ Issued ............................. ..........................-..........
Date
TOWN OF BARNSTABLE
LOCATION duct.4P_Caa,i WD SEWAGE # Y
VILLAGE. C,. ASSESSOR'S MAP & LOT Q Iq- I a 7.
INSTALLER'S NAME & PHONE NO
SEPTIC TANK. CAPACITY ) &-0 Q
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS. PRIYATE WELL OR PUB I . - ATER
BUILDER OR OWNER C..T PtiU
DATE PERMIT ISSUED: j - 2
DATE COMPLIANCE ISSUED: i
VARIANCE GRANTED: Yes No
c
}
• - � :sir.—�:� • ..
i
0
MRVP # �
Assessor's Office (1st Floor) f •�
Assessor's Map and Parcel # Cl/ / F6
w�ll
Building Department (4th Flo r)
zoning
INSPECTI 0.00
RE-INSPECTION FE $15.00
Request For A Housing Inspection For Certification Under the
MA Rental Voucher Program
Your Name
Affiliation (Circle One) Owne Real Estate Agent Tenant
Your Address (S`L. Nrn ke gnu k n 6c�M , T- LMt4
Telephone Number (Day) (Night)
$'
Address of Property Where Ins ection is Requested
Unit/Apt.# l a AJIGrr'Acan! Q�' a=d A
Name of Owner /
Address C, S'0-d ` �*
Mailing Address (if different)
Telephone Number (Day) 4.*�R-2&ge (Night)
Will there be any children under the age of six (6) who will
be occupying the rental unit? (circle one) Yes 1<00
Was the dwelling constructed prior to 1979? Yes
------------------------------------------------------------
FOR OFFICE USE ONLY:
Certification
The dwell' dwelling unit, or rooming unit located at
Pi�f1 . -�� � was inspected on
by Health
Inspector for the Town of Barnstable and was found to be in
compliance with the provisions contained within 105 CMR
410.00, State Sanitary Code II: Minimum Standards of Fitness
for Human Habitation. However, this certification does not
include a determination as to whether this -unit contains any
lead paint because under 760 CMR 49.02 Massachusetts Rental
Voucher Program, a separate lead paint inspection must be
conducted.
Inspector's Signature 4�-
Date-
r
i )y
MRVP #
Assessor's office (1st Floor)
Assessor's Map and Parcel #
Building Department (4th Flo r)
Zoning
I-NSPECTI, 0.0 0
RE-INSPECTION FEE $15.00
Request For A Housing Inspection For Certificaation Under the
MA Rental Voucher Program
Your Name -I h0 Wt A IS
Affiliation (Circle One) Owne Real Estate Agent Tenant
Your Address f 32 �lrf�p_2 env 1 h �U t -F �(A
!� 03
Telephone Number (Day) S'o���F��t.�-9(05 Q (Night) S 4.,F_
Address of Property Where Inspection is Requested
Unit/Apt.# t 3 kitGreP&_C&J P n �' oa-ur !�A
M Name of Owner
Address L9 a. c S'an/ Ipvc-
Mailing Address (if different)
Telephone Number (Day) . -�l�C� (Night)
jWill there be any children under the age of six (6) who will ,
be occupying. the rental unit? (circle one) Yes
g k p 9 - 9r /Y/espy ' ° �a
Was the dwell ' constructed prior toi ,
---------------------------------------------------- ------
FOR OFFICE USE ONLY:
Certification
,$ The dwell�i� dwelling unit, or rooming unit located at
was inspected on
by c�r?,PrZ 5./ t Health
r Inspector for the Town of Barnstable and was found, to be in
compliance with tYhe provisions contained within- 105 CMR
410.00, State Sanitary Code II: Minimum Standards of Fitness
for Human Habitation. , However, this certification does not
include a determination as to whetherthIsunit contains any
lead paint because under 760 CMR 49.02 Massachusetts Rental
Voucher Program, a separate lead paint inspection must be
conducted. w '
Inspector's �ignature
Date'
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION
Date
Owner Tenant `
Address Address
Compliance Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities $✓
8. Ventilation ,�✓
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural d [�
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal` �G �
16. Sewage Disposal -r �/
17. Temporary Housing
PART II P!o""4vn °v`40 "Ve 7
of Condemned Dwelling; F4-4 .,9 -�
37. Placardin
9 g; e 4 0�A-rel '
Removal of Occupants; Demolition. �2 ew� W or�f1.1 0
Person(s)Interviewe4
Inspect =�
If Public Building such as Store or Hotel/Motel specify here
HOBBS&WARREN.INC.
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Of C A T 1 O 13 \12b(�g SEWAGE P E MIT -0.
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V'ILLAGE
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INST,A LL ,R'S A M E & ADDRESS
— OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED '
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
Application -for Disposal Morks Tonstrurtion Vrrnift
Application is hereby`made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
........�
ocation-Address or Lot No.
......................... . -- -• ...................•--.......................................
Owner Address
•-- C;•-- -----------------------------------••---- ---•-----._....-----•......-•-------•- ----•------•-••-••----•----•-•-•----••----
Installer Address
Q Type of'Buildin Size Lot.....__-A_4._C±- --- feet
U Dwelling,7No. of Bedrooms---- ...................................Expansion Attic (J.4)0 Garbage Grinder ( )
aOther—Type
of Building ___l-_CC_�_ a_2__ No. •f persons........ _____________ Showers ( ) — Cafeteria ( )
Q Other fixtures -------------------------------------------------------------
WDesign Flow....................................``...�._aa gallons per person per day. Total daily flow---------_---_--_-_-_-_____-_,____-----.--..gallons.
WSeptic Tack L Liquid capacity/_a" d-gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No- -------------------- Widtll_�__�.__j___f�� "Total Length.-.-___-_-___--_-_ Total leaching area--------------......sq. ft.
Seepage Pit No. Diameter. th belo inlet --- ------. Total leaching area sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) .4 �L/ j_ !y-11 —7 7 ,
aPercolation Test Results Performed bY.......................................................................... Date---------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
(Xq Test Pit No. 2................minutes per inch Depth of Test Pit.--___-_-_-------_- Depth to ground water.-.-.-----.-----_.-_.._.
i ---... __
0 Description of Soil......19 ----a.. �I --- j�--•-_--
-- WU --------
_____________A______-------..
---------------- ------------- __ -- -- -� o� 0----- ' L.
-----------
U Nature of Repairs or Alteratio —An ver when applicable.-.---_-------------------------- -
---- ----------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasAbbeissued,by the boardo ealth.
Sign . -`--- _.
.......
=,F- ------.
--••-•............................................Date ......----
Application Disapproved for the following reasons:.............................. .. •_ �
.---------•-••--------------------------•-------------------------•--------- --------•----•------------ ------------.-----
Date
Permit No........................................ Issued...... . . . .. ...7...
Date
�, ------------------------------- -
{
Fug.... .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
.... . La .........- OF ::'.: °< I ........................................
Appliral.ton -for 43t�ipmat orko t;Lanstrurtion erns
Application is hereby'made for a Permit to Construct. (<.... ) .or Repair ( ) an Individual Sewage Disposal
System at p
r1.� 1
ocation-Address �+ or Lot No.
Owner Address
a1. ---•- --•- .........
r Installer Address
..,..:.,c .,�4
Q Type of BuildingSize Lot_____________ _C,_f!_lq. feet
a .3 .ram ------------Expansion Attic (�/ Garbage Grinder
( )
Dwellin No. off"Bedrooms_._ ..________________________
a Other—Type of Building ft.11.Ma_�... No. of pei-solis------Z----------_------ Showers ( ) — Cafeteria ( )
Q Other fixtures --
-,.
. ....................
W Design Flow............................................gallons per person per day. Total daily flow..................................t...._'_...gallons.
P4 Septic Tank—Liquid capacity____-______gallons Length................ Width............ Diameter__.__..._.._____ Depth....______._.._
xDisposal Trench—No_____________ ______ Width-------------------- Total Length_._.._____._..._.__Total leaching area_.......___.e-----sq. ft.
Seepage Pit No___________ ____ Diameter-------------------- Depth belo inle��� � otal leaching area.........�'-___ sq ft' j
z Other Distribution box ( Dosing tank0
7
f-I
a Percolation Test Results Performed by--------------------------------------- -- ------------........... Date-----------------------------------i,_.
Test Pit. No. L_____________r_minutes per inch Depth of Test�Alt._.-.._.---_--__-___ Depth to ground water_._.______.__;.__...
f14 Test Pit-No. 2................minutes per inch Depth of Test'Pit___..............___ Depth to ground water...-_._._______-____-
O Description of Soil -fk �,,, ' --
______________________________________________________________________________________________'____.-________-.- ----------------------------------------------
.-_- . ___-_.________-_-- -------------
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------- ------.__.----------------------
-------------------------------------------------------------------------------------------------------------------- ....
=`= '= •.
-
f.
Agreement: 1
The undersigned agrees to install the aforedescribed Individual Sewage.Disposid System in accordance with
the provisions of Article 1I of the State Sanitary.Code—The undersigned-further agrees not; place the system-in
operation until a Certificate of Compliance has b issued'by the board � ealth. !.
z.
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Sign, •!• �1 !`
}
� !_.-
Date
Application Approved By---���--- -... `` ............. ----------
Date
Application Disapproved for the following reasons:---------------------------• •-------•----------------I-----------••---•--------------------------•--••-----
f'
. ........................................................................................._....._....................______.____......___._...__....__._.______._._.____......_______...._.._._._.......
Date
PermitNo..................................................... Issued........................................................
Date
THE COMMONWEAL OF MASSACHUSETTS
1304RD/_�§KlnLTH
y...»
,,::.OF. ....... ................ ............................................
Trrtifirate of ompligurr
RfIF �T t � Individual S a e 1 stem constructed ( ) or Repaired
--- ------•-•----•---•-------•-•••-•••----•••-------------•-------......---•----•••-
�allcr
at •.�... ------------------------------------------- ` - - -- •-•-•-•-•-•-----------•------
� f„:._ �' `
has been _ istalled in accordance with the provisions of Article of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__=`__"'.... .......................... dated_._._____..-----___________.__---___-------_--
,THE ISSUANCE OF THIS CERT4FlCATFr"SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
l!DATE. v7 -'; Inspe tor-.-..•... -------- C
--------------------------------
- Af
f f THE COMMONW L:TH OF MASSACHUSETTS
' BOAR& ALTH
OF
No.................. H ;r FEE
ete
}, u1sp ]� a� �r�tr tea Urrmif
I' im i�i� e1 } rant dGt Lr {$ ...............—. '�' " -fit€ t" '
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo. -------------------------------------•---•--=•.................................. -- ------- -------- ------ -
as shown on the application for Disposal Works Construction ]hermit No------------- t . :_+...................................
••----••-----•----•---.---- --:... ---------------•---•-----------•----------
- Board of''Heal'th
DATE..................--------- f.
FORM 1255.'HOBBS & WARREN:• INC., PUBLISHERS
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