HomeMy WebLinkAbout0334 OLD OYSTER ROAD - Health �'� ou
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
334 Old Oyster Rd
Property Address
t�Q
John Holt
Owner O ~
wner's Na ?}
information isf
required for Cotuit ✓ Ma 23-16
every page. Cityrrown State Zip Code Da.Wof Inspection
1\71
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 A. General Information /
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN,INC
Company Name
P.O. BOX 145
Company Address .
CENTERVILLE MA 02632
City/Town State ,Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
�� 2 23-16
Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
reportto 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 Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for COtult Ma 2-23-16
every page. Cityrrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. THIS REPORT DOES
NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
p o
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND :below
(Explain )
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland-or a salt marsh
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
II
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy Y 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
0 ® 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 '/2 day flow
t5ins•3/13 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
334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every;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.
❑ E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
I
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
F Tit
le 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health. ,
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3per
assessing
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 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
G M , 334 Old Oyster Rd
Property Address
John Holt
Owner Owners Name
information is required for Cotuit Ma :2-23-16
eve page. Citylrown State Zip Code Date of Inspection
P
every 9 P
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 1000 GALLON TANK D-BOX
AND 2 60 FT TRENCHES.
Number of current residents: 2
a
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d N.A.
9 ( Y 9 (gP ))� _
Detail:
SYSTEM IS NOT DESIGNED FOR USE WITH A GARBAGE DISPOSAL-
Sump:pump? ❑ Yes ❑ No
Last date of occupancy:. _ Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow,(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-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
M 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENTLY OCCUPIED
Date
Other(describe below):
General Information
Pumping Records:
Source of information: _ DEBARROS SEPTIC
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was Y uantit pumped determined? TANK TRUCK
q
Reason for pumping: MAINTENANCE
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 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
>''rV 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
APPEAR TO BE ORIGINAL
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 GALLON
Sludge depth: MODERATE
t5ins-3/13 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
GSM , 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness LIGHT
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? MEASURED WITH WOODEN
POLE
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK WAS PUMPED AT TIME OF INSPECTION FOR MAINTENANCE. RECOMMEND PUMPING
EVERY 2-3 YRS FOR MAINTENANCE
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°,M s 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM , 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Oil
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box etc.):
:)
BOX LEVEL NO LEAKAGE SOME SIGNS OF CORROSION TYPICAL FOR ITS AGE. WE
INSTALLED A NEW TOP BECAUSE THE OTHER ONE WAS CRACKED. RECOMMEND
INSTALLING RISER TO BRING COVER CLOSER TO GRADE.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
NO OBSERVATION PORTS LOCATED.
t5ins•3/13 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
334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑
leaching
number:
❑ leaching galleries number:
® leaching trenches number, length: 2-60 FT per as-
built
❑ 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.):
no observation ports were located so we were unable to determine the level of ponding. there were
no evident signs of failure it the general area of the s.a.s
9
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 334 Old Oyster Rd
Property Address
John Holt
Owner Owners Name
information is required for Cotuit Ma 2-23-16
every page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
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 Voluntary Assessments
334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: GREATER THAN 5
feet
Please indicate all methods used to determine the high groundwater 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 mu
st describe how you established the high ground water elevation:
PROPERTY IS NOT IN AN AREA OF HIGH GROUND WATER.
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
I�_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 334 Old Oyster Rd
Property Address
John Holt
Owner Owner's Name
information is required for Cotuit Ma 2-23-16
every page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17
.Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE
4 LOCATION ?�[01c. �V STPr PC( SEWAGE#
�yA�F �oTti: ASSESSOR'S MAP&LOT
INSTAL.LER'S NANE&PHONE NO._ 1
SEPTIC TANK-CAPACrrY
LEAt33ING PACII.ITY:(tYPe)�r '"�-. S (siu)
NO.OPSOROOMS 3-- I
BUILDER OR OWNER
FERMITDATE; COMPUANCE DATM
Soparation Distance Between the:
Maximum Adjusted GroundwattrTableto the BottnnofLeachingpaeility
Private Water Supply Well andLcaching P=14(If any Wells exist
on site or witltie 200 feet of leaehiog fnclity) ---
Edge of Wedand and UacitingFacility Of any Wdlands exist
within 340 feetpf Ic"Itiag IaCiiiry)
RaT isshed by
U0
c !'
i
I
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=022127&seq=1 2/23/2016
. vim✓'^
Commonwealth of Massachusetts
f.
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is equired for Cotuit MA 02635 6-12-08
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.
A. General Information
1. Inspector.
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification -
I certify that I have personally inspected the sewage disposal system at this addr ss and%, th
information reported below is true, accurate and complete as of the time of the Insppection.jhe iris`pection
was performed based on my training and experience in the proper function and maintenarfae of onsite
sewage disposal systems. I am a DEP approved system inspector pursuant to.� ectiort45.340_-of
itle 5 (310 CMR 15.000).The system: w `
r� ® Passes r ❑ Conditionally Passes } ❑ F at
W
❑ Needs Further Evaluation by the Local Approving Authority. — -
to -
6. i
6-13-08
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of,Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the .
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer; if applicable, and the approving authority.
****This report only describes conditions at the time.of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Recommend pumping now and every 2 years for maintenance. -
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page,t of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal`or not)is
structurally unsound, exhibits.substantial infiltration or exfiltration,or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying Septic tank as
approved by the Board of Health. I
. !"tt
* A metal septic tank will pass inspection if it is structurally sound, not leaking and If a Certificate
of Compliance indicating that the tank is less than 20 years old is available. )
ND Explain:
i
❑ 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 distributionfbox=System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name ^
information is required for Cotuit = MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): r
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water '
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail•unless the Board of Health (and Public Water Supplier, if any)
t determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water.
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
°wM 334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the 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.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments..
,M 334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
® r Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑. ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,.therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. f
For large systems, you must indicate either`fires"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑' rthe system is within 200 feet of a tributary to a surface,drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protect ion
E] ❑ Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of.75
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or:"no" as to each,of the following:
Yes No
❑ ® 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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure_criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CM 15.302(5)]
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;
M 334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330
Number of current residents: 'e 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse?, ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: Date 8
Date
Commercial/Industrial Flow Conditions:
'Type of Establishment: • " '
Design flow(based on 310 CMR 15.203):
_ - Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): -
Grease trap present? El Yes ❑ No
Industrial.waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
°M 334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08.
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 36"
'feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):.
Good condition.
Septic Tank(locate on site plan):
Depth below grade:. 30"
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: 4,
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000 Gal
12"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle -
20"
Scum thickness ,
Distance from top:of scum to top of outlet tee or baffle 6 `
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? Tape
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
L '
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
334 Old Oyster Rd
Property Address
James Lindsley
Owner 'Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.): }
Tank in good condition with baffles in place. Tank is structurally sound with no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle -
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow:F.
gallons per day
Alarm present: ❑, ,Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
1�,
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.):
D-box in good condition with stain line at 1" above outlet invert. Shows that field has reached about
70% of capacity.
Pump Chamber(locate on site plan): '
.Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes " ❑ No
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15.
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°wM 334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type: "
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
number, length:
® leaching trenches the 2-60'g
❑ 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.):
Visual inspection of stone in trench shows no sign of break-out but stains on stone indicate trench
had reached about 70% of its capacity.
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts ,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
334 Old Oyster Rd
Property Address _
James Lindsley
Owner Owner's Name -
information is required for Cotuit MA 02635 6-12-08 r=
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration -
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction _
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
LI5 ,
00i-
� Y
c�
t5lnsp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 334 Old Oyster Rd
Property Address
James Lindsley
Owner Owner's Name
information is required for Cotuit MA 02635 6-12-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 25
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 describe how you established the high ground water elevation:
USG and town maps show no water within 10'.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of15
f r o r� y
wn
o
yip yo Regulatory Services
t BARNSTABLE, « Thomas F. Creiler, Director
�prEava Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC
TOWN OF BARNSTABLE
LOCATIONPr c(ICCc( �SEWAGE #
VMLAGE -��4� A,SSESSOWS '&LOT
-INSTAl;.ILEWS NAME&PHONE NO.
SEMC TANK CA,PACn.Y
LEACH,ING FACILITY"; (type) r %" C(�S _ __.(size) Q
P O,OF'k� ,1�1�CO�ils_ 3
WILDER OR
t'FRR MATDA7E,.a...,_...,,,..w._____—":w COWLI.A,NCE DAIT-.,.
Separation Distance,Bctwogi the.
MAXirnittn Atljtrsttrd Utauntlwrtte['�t�le tt}tlto 1(3crttnm nt�,�at<hin�Fat;ility �a., ���"�?
Privao Water Supply Well sold Leashing Facility (If any wells exist
on site or witWo 200 feet of leaching facility)
Edge of Weiland and UachingFacility(if any wetlands exist
within 300 feet t'lcaclung larility) �ILeet
Furnished y
i ( n
i
'..
t
A 6 {� �-�- ��' tic �s
�6�
a��
��
r I- '�
1
i,
TOWV OF BARNSTABLE
LOCATION �� s � �� SEWAGE #
VILLAGEc--fo-u-yl ASSESSOR'S MAP & LOT
®IZ
INSTALLER'S NAME & PHONE NO. �/�G
SEPTIC TANK CAPACITY / /)-—/0
LEACHING FACILlTY:(tyge).--,z (size) 6 -
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER PLie(f��
BUILDER OR OWNER ZINbs ..
DATE PERMIT ISSUER:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
A= /.6 `
48
C714
1 .
AS ft'170 FA
NOA zjs�r PARCEL We
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F H AL
.........................................OF..... .-... .-CC _-. ..". .................._.
Alip ira#ivaa for Uispoa al Workri Tuaautrurtiuu ramit
Application is hereby de for a ermit to .0 struct'( or Repair ( ) an Individual Sewage Disposal
System at, 7... -••••---•--•-•---... ... -.
. .. ... ..... . . ... .... . .........
.. ....
Lo A res r
--
Owner + Address
a ...................�e..... . . ... ...................................... .......��• ...!. .... .G ... ....._.._.....
In ler Address lo
Type of Building Size Lot...... . .................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
Other—Type of Building No. of persons............................ Showers — Cafeteria
a Other fixtures --------------------------------- .
W Design Flow---------------------------
-----------------gallons per person per day. Total daily flow............................................gallons.
� Septic Tank/—Liquid capacity/gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
'k Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2.......:........minutes per inch Depth of Test Pit..................... Depth to ground water........................
-------••-------------•---••-•-•----•--...--•-•-------••-------•--••----••----......-----.............--•-•----------.......---------------------......------
0 Description of Soil.......................................................................................................................................................................
x
V ....
---•----------------------------------------------
-----------
•---------------------------------------------------------
•---------------------------------------
•--------------------
.----------
W ----------•-------------------------------------------------------•--------------------------------•---------------•--------------•--------•---------------------------•-----------------------.......--
VNature of Repairs or Alterations—Answer when applicable....--.................................:........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'L 1E 5 of the State Sanitary Code—The undersi d further agr snot to place the system in
operation until a Certificate of Compliance has been i sued b e b rd of hexlt
Signed------. : ..-- ......................
a
Z4
Application Approved B ---:_- .... �1 � — ..` ...- -� C_ `�_ `..
Date
TOWt4 OF BARNSTABLE
WAGE # '1
LOCATION SE
VILLAGE
/�-'f I ASSESSOR'S MAP & LOT
INSTALLER'S NAME PHONE NO.--&(2
SEPTIC TANK CAPACITY jn� A/—10
` (size)
LEACHING FACILITYAtype)'c
NO. OF
BEDROOMS PRIVATE WELL OR PUBLIC WATER Py�L/C(Mi
BUILDER OR OWNER
—Dk-
DATE.PERMIT ISSUED:
DATE ..COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes NO
A= Jgo�s�
)c 67
_ E35i
'A
W Ilk
No------------------------- FEE............._...._....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT*H/-/'
...........................................
.......................
.................
Allpfiration for Dispoiial Works Tonstrurtion ramit
Application is hereby mde,for a J"ermit to Construct ( tor Repair an Individual Sewage Disposal
System at.:,,
7 te bi-i
2.,; .. -.4.......................
........ 01 ................ Z.....................................
1�o��ion.i AdAre.SfF� -v br N
.......................:_fey ....... ...... ....... .........
Owner Address,,el`
...................................... ..............
..................... ......... :*.............
Installer Address
Type of Building Size Lot...... feet
-.Dwelling—No. of Bedrooms............ .:)
..............................Expansion Attic Garbage Grinder (41
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter--._--_-___---_- Depth......._.._.....
Disposal Trench—No. .................... Width.................... Total Length.._............_.... Total leaching area....................sq. f t.
Seepage Pit No..................... Diameter.._................. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.._.._.............. Depth to ground water--------_---_----------.
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit................__.. Depth to ground water............._......_...
Ix .............................................................................................................................................................
0 Description of Soil........................................................................................................................................................................
W
U .........................................................................................................................................................................................................
.....................................................................................................................................I..................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'1'11 5 of the State Sanitary Code— The undersigned further agr�s not to place the system in
operation until a Certificate of Compliance has been i u d b/," e kp arc�of holt4!*,
�c 4/
Signed......... ...................................11�........................ ---
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:..............................................................................................................
.......................................................................................................................................................................................................
Date
r'l — 5Permt No................. .............. Issued.---------------------.....-----------............-----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(9prfifirate of Tontlitiattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at---------------------------------------------•--•---•-------------..._.....-•------•----•-------------------------........---•-------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary 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................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF...................................................................................
No......................... FEE........................
Disposal Works 0141notrudiatt "prratit
Permissionis hereby granted.......................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo........................................................................................................... ...................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated.._................._..._.................
.......................................................................................................
Board of Health
DATE. .................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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APPLICATION FOR P' RCOLA ION TES'Z AND OBS_ R ATION. PITS. V
CATI_O .0 ! NO. f �� r
1ILLAGE DATE
,PPLICANT . FEE
:DDRESS ; ` TELEPHONE NO. (Non-refundable)
;NGINEER c� TELEPHONE NO
)ATE SCHEDULED � �` l
�� _ 1 (Applicant's signat re)
ASSESSOR'S MAP LOT NO: / SOIL LOG . Zf3
;UB-DIVISION NAME OC) Lce l�c� DATE �'' �+�� TTP2E
;XPANS ION AREA• YES " NO r ENG
'OWN WATER 2 PRIVATE WELL BOARD OF HEALTH
EXCAVATOR
;KETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to. test holes)
• NOTES:
�32 9.9
m
m
4362E
_G
�- - N
J
13.98
11
?ERCOLATION RATE: 2 m tq _ , L055
PEST HOLE NO: I ELEVATION: TEST HOLE NO: ELEVATION:
2 2"d 1_Aj m+L -:l0"A A 2
3 �'� 2► B _ u 3
5 5 SAW6
8 8
9 9
]0 10 _
' 11
6
8 8
9 9
10 10
11 11
12 12
_ 13 13
14 14 j
15 15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEAC G PITS
LEACHING TRENCHES_.
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED -ON PERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY-P. E. AND RETURNED_-TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT
�l •
334 OLD OYSTER R04 COTUIT
A=022-127