HomeMy WebLinkAbout0350 OLD OYSTER ROAD - Health 350 Old Oyster .RQQQ _Cotuit _
L A = 022 126
Commonwealth of Massachusetts � � 0co?"(
Title 5 Official Inspection Form
'.� 7. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
d '4 350 Old Oyster Road '
Property Address
Earl Phillips
Owner Owner's Nam
information is
required for every 9 Cotuit MA 02635 August 18, 20201
_
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may.not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information 's Iy '),a..
filling out forms
on the computer,
use only the tab Patrick T. Sullivan
key to move your Name of Inspector
cursor-do not Ready Rooter Excavating -
use the return Company Name
key.
PO Box 89 `
s 11 Company Address
Forestdale MA 02644
City/Town State Zip Code
508-509-0802 S112843
Telephone Number License Number
B. Certification `
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. Passes .
2. Conditionally.Passes -
3. 0 Needs Further Evaluation by the Local Approving Authority
4. Fails
August 20, 2020
In oes 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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
' regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the "
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
............c� 350 Old Oyster Road
u
Property Address
Earl Phillips
Owner Owner's Name
information is 9 required for every Cotuit _ MA 02635 August 18, 2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infi�ation 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
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that he tank is less than 20 years old is available.
i
❑ Y ❑ N f ❑ ND (Explain below):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c Commonwealth of Massachusetts
= Title 5 Official Inspection Form
P Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
350 Old Oyster Road
Property Address
Earl Phillips
Owner Owner's Name
information is Cotuit MA x 02635 August 18, 2020
required for every 9
page, City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) _
2) System Conditionally Passes (cont.):,
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ . Observation-of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or dine to a broken, settled or uneven distribution box. System will
pass inspection if,(with approval 9f Board of Health):
❑ r broken pipe(s) are rep)aced ❑ Y ❑,N ❑ ND (Explain below):
❑ obstruction is remo ed ❑ Y ❑ N ❑ 'ND (Explain below):
❑, distribution box is eveled or replaced ❑ Y. ❑ N ❑ ND (Explain below):
f
❑ 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 {ElND (Explain below):,
3) . Further Evaluation is Requireo by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in-order to determine if
the system is failing to protect public health, safety or,the environment.
a. System will passunless Board.of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 18^ ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
350 Old Oyster Road
Property Address
Earl Phillips
Owner Owner's Name
information is 9 required for every Cotuit MA 02635 August 18 2020
_-
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water•
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board ofr19ealth (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 tanl�and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic t a�k and SAS and the SAS is less thari 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine d�tance:
**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. I
r
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
. t
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
El z due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
a
Commonwealth of Massachusetts
,�p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments
350 Old Oyster Road
Property Address
Earl Phillips
Owner Owner's Name
information is Cotuit MA 02635 August 18 2020
required for every g ,
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cunt.)
Yes No
❑ - ® Static liquid level in the;distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool I
❑ ® Liquid depth in cesspool is less than 6" below.invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 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 CA.
Yes No
❑ ❑ the system is within 40 feet of a surface drinking water supply -
❑ ❑ the system is within; 00 feet of a tributary to a surface drinking water supply
El ❑ the system is iocaIed in..a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 18
f
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road _
Property Address
Earl Phillips
Owner Owner's Name
information is Cotuit MA 02635 -August 18, 2020
required for every — — _ 9
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction;
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?.
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ 'Existing information. For example, a plan at the'Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
1p Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e � 350 Old Oyster Road
Property Address
Earl Phillips
Owner Owner's Name
information is Cotuit MA 02635 August 18 2020
required for every g ,
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow'Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for exampie:.110 gpd x#of bedrooms):' 330 GPD
Description:
Number of current residents' . 2
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit?' ® Yes ❑ No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑' Yes ® No
Water meter readings, if available last 2 ears usage 2018= 243 GPD"
9 ( Y 9 (gpd))�� � 2019= 243 GPD#
Detail:
"High water usage during summer months due to irrigation. Recommend removal of garbage
disposal.
Sump pump? ❑ Yes ® No
Last date,of occupancy: Current
Date -
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
► Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
f^
350 Old Oyster Road
Property Address
Earl Phillips
Owner Owner's Name
information is Cotuit MA' 02635 August 18, 2020
required for every 9
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203, Gallons per day(gpd)
Basis of design flow(seats/persons/sq'ft., etc.):
Grease trap present? /( ❑ Yes ❑ No
Water treatment unit resent? El Yes No
If yes, discharges to:
Industrial waste holding tank pr sent? ❑ Yes ❑ No
Non-sanitary waste discharge to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/u$e: Date
i
Other(describe below
3. Pumping Records:
Source of information: Ready Rooter.records: Pumped Fall 2018
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: -
gallons
How was quantity pumped determined? -- -
Reason for pumping: - —
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
,lp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
350 Old Oyster Road
Property Address
Earl Phillips
Owner Owner's Name
information is u
Cotuit MA 02635 Au st 18, 2020
required for every g
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single,cesspool
❑ Overflow cesspool
❑. Privy
❑ 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:
Septic tank d-box and leach pit 30 years old. 2nd d-box and leach trenches added Jan. 6, 1997. As-
built and permit on file at Health Dept.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.2
feet
Material of construction:
❑ cast iron N 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: n/a
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of-Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road
Property Address
Earl Phillips
Owner Owners Name
information is COtUIt
required for every MA 02635 August 18, 2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
1.5
P
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: 8.5'x 4.5'x 5' 1000 allons
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness
<1"
Distance from top of scum to top of outlet tee or baffle
101,
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Dip tube and tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee and outlet concrete baffle in place. Liquid level at outlet invert. Risers bring covers within 6"
of grade. Recommend maintenance pumping every two years with full time use
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection _Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e � 350 Old Oyster Road
Property Address
Earl Phillips w
Owner Owner's Name
information is August 18, 20209
Cotuit MA 02635 Aug
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete' ❑ metal ❑ fiberglass El 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.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal i/ ❑ fiberglass ❑ polyethylene ❑ other(explain):
i
f
f
Dimensions:
p
A /
Capacity: j
gallons
Design Flow:
. gallons per day
t5insp.doc-rev.7l2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road
Property Address
Earl Phillips
Owner Owner's Name -
information is Cotuit _ MA 02635 August 18, 2020
required for every g
page. City/Town State Zip Code_ Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: , ❑ Yes ❑ No
Alarm level: P5'— Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float witches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0.1
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.):
#1-One inlet, two outlet. Flow going to leach pit. #2- Liquid level 1/4" below inverts. No solid
carryover. Riser brings cover within 6" of grade.
t5irisp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - of for Voluntary Assessments
350 Old Oyster Road
Property Address
Earl Phillips
Owner Owners Name
information is Cotuit MA 02635 August 18, 2020
required for every 9
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ .No*
Alarms in working order:' ❑- Yes ❑ No*
Comments (note condition of pump cha/-er, ndition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1-6'x6'w/stone
❑ leaching chambers number:.
k
❑ leaching.galleries number:
® Teaching trenches number, length: 2-38' x 2'x 2'
❑ leaching fields number, dimensions:
overflow cesspool _number:
❑ innovative/alternative system
r
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road
Property Address
Earl Phillips
Owner Owner's Name
information is Cotuit MA 02635 August 18 2020
required for every 9 ,
page. City/Town State Zip Code_ Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Camera used to inspect leach lines. Dry at time of inspection. No high water staining over
perforations. No sign of past hydraulic failure.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments note condition of, signs of hydraulic failure level of ondin condition of vegetation,
( / g Y P 9, 9 ,
etc.):
j
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
13,
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road _
Property Address
Earl Phillips
Owner Owner's Name
information is Cotuit - MA 02635 August 18 2020
required for every g ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:.
Dimensions
Depth of solids -
Comments (note condition of soil, signs of hydr ulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
350 Old Oyster Road
UV -
Property Address
Earl Phillips
Owner Owner's Name
nformation
(required for every Cotult MA 02635 August 18, 2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
i
' t-
Iias 3p?'
4"4
Ay3�` 1
1 1
S
1 i
t5insp.doc•rev.7r-A5=16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
/ 350 Old Oyster Road
Property Address
Earl Phillips
Owner Owner's Name
information is Cotuit MA. - 02635 August 18 2020
required for every g ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
r
❑ Shallow wells
Estimated depth to high ground water: 30+ - —
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: Jan 1997
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:
maps.massg is.state.ma.us/oliver.phi
You must describe how you established the high ground water elevation:
Test hole in 1997 found no ground water at 10'. Base of trench at 5'. Property elv= 50. local ground
water contours shows ground water at elv= 15+-. No high ground water in area of system.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road
L
Property Address
Earl Phillips
Owner Owner's Name
information is Cotuit MA 02635 August 18, 2020
required for every _ 9
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
0
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form opy .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27 2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form..Inspection forms may not be altered in any
way.
Important: A. General Information �/��
When filling out r
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick T. Sullivan
cursor-do not Name of Inspector
use.the return
key. Ready Rooter, Inc.
Company Name
L PO Box 371 -17 Jan Sebastian Dr.
Company Address
Sandwich MA 02563
Cityrrown State Zip Code
508-888-2805 S112843
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that thei
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 diPsite
sewage disposal systems. I am a DEP g p y approved system inspector pursuantto Sectionl15.34�;of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ FTils CIO
ca
❑ Needs Further Evaluation by the Local Approving Authority ,;j M
October 28, 2009
Inspector's nature 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. LJ .
V
350oldoysterrd•03/08 Title 5 Official Inspection For Subsurface sewa•e Disposal System•Page 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27, 2009
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:
® 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:
Recommend removal of garbage disposal. Recommend maintenance pumping yearly if not removed.
*High water usage during summer months due to irrigation.
B) System Conditionally Passes:
❑ One or more system components as described in the", onditional Pass" section need to be
replaced or repaired. The system, upon completion o he 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 * or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial i iltration or exfiltration or tank failure is imminent.
System will pass inspection if the existin tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass insp tion if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the ank is less than 20 years old is available.
ND Explain:
❑ Observation of se age backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
-❑ broken pipe(s) are replaced
❑ obstruction is removed
350oldoysterrd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2
Commonwealth of Massachusetts
w - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is Barnstable MA 02630 October 27 2009
required for ,
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more t an 4 times a year due to broken or obstructed pipe(s). The
system will pass inspectio/repla
proval of the Board of Health):
❑ broken pipe(s) arobstruction is rem
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'e vironment.
1. System will pass unless Board of Health determi es in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in anner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a s rface water
❑ Cesspool or privy is within 50 feet o a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board Health (and Public Water Supplier, if any)
determines that the system is func ' ning in a manner that protects the public health,
safety and environment:
❑ The system has a septic nk and soil absorption system (SAS) and the SAS is within
100 feet of a surface w er supply or tributary to a surface water supply.
❑ The system has a Sep 'c tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a se tic tank and SAS and the SAS is within 50 feet of a private water
supply well.
350oldoysterrd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27 2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.
❑ The system has a septic tank and SAS and the SAS is les 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, p rtormed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of a monia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure riteria 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
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® 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 '/z 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.
350oldoysterrd-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27 2009
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.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"t ach of the following, in addition to the
questions in Section D.
Yes No
❑ '❑ the system is within 400 et of a surface drinking water supply
❑ ❑ the system is withi 00 feet of a tributary to a surface drinking water supply
Elthe system is I ated in a nitrogen sensitive area (Interim Wellhead Protection
El
Area—IWP or a mapped Zone II of a public water supply well
If you have answered "yes"to y question in Section E the system is considered a significant threat,
or answered "yes" in Sectio above the large system has failed. The owner or operator of any large
system considered a sign' cant threat under Section E or failed under Section D shall upgrade'the
system in accordance th 310 CMR 15.304.. The system owner should contact the appropriate
regional office of the Department.
350oldoysterrd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is Barnstable MA 02630 October 27, 2009
required for
every 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:
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)]
350oldoyslerrd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
t Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27, 2009
every page. CityTrown 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 GPD
Number of current residents: 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 ears d 2008=495 GPD*
g ' ( y usage g (gpd)): 2009=410 GPD*
Sump pump? ❑ Yes ❑ No
Last date of occupancy: CurrentDate
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 T' le 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
350oldoysterrd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage bisposal System Form -Not for Voluntary Assessments
M 350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is Barnstable MA 02630 October 27 2009
required for ,
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Owners records: Last pumped 2008 (every 2 years)
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:
Tank, 1" D=Box and leach pit approx. 20 years old. 2"d D-Box and leach trenches added Jan 6, 1997.
As-built and permit on file at Board of Health.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
350oldoysterrd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is Barnstable MA 02630 October 27 2009
required for ,
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
271
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance,from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 116"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:
8.5' X 4.5'X 5' 1000 gallons
Sludge depth: 21'
Distance from top of sludge to bottom of outlet tee or baffle
' 32"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle 811
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? Tape measure and dip tube.
350oldoysterrd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27, 2009
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet PVC tee and outlet concrete baffle in place. Liquid level at outlet invert. No sign of leakage.
Risers bring covers within 6"of grade.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
I
El concrete , El metal iberglass El polyethylene [I other(explain):
Dimensions:
Scum thickness
Distance from top of scum o 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 i pection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal fiberglass ❑ polyethylene ❑ other(explain):
350oldoysterrd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27, 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: Mons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level.' 7 Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
#1-One inlet, two outlets, equal flow. No solids carryover. #2-One inlet, two outlets, equal flow. D-
box is Poly with ADS riser and concrete cover within 6"of grade. No high water staining over outlet
inverts.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
350oldoysterrd-03/08 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27, 2009
every page. Citylrown 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: 1-6'X 6'w/
stone
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2-38'X 2'X 2'
❑ leaching fields number, dimensions:
a
❑ 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.):
Camera used to inspect leach lines. No sign of high water staining or past hydraulic failure. Hand
probing found no ponding over and around SAS.
350oldoysterrd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27, 2009
every page. Cityfrown . 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
i
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, Igns of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of draulic failure, level of ponding, condition of vegetation,
etc.):
tz
350oldoysterrd•03/68 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 113 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27, 2009
every page. City/Town 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.
I i
tS. t _ tt 3ti � 33 `
a1 0
/ 0
.i
I
. I
1, ., �, , ,.,i,;• /
350oldoysterrd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
350 Old Oyster Road Cotuit, MA 02635
Property Address
Deborah Corcoran P.O. Box 13
Owner Owner's Name
information is required for Barnstable MA 02630 October 27 2009
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: 30
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: Jan 1997
-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:
ma.water.usgs.gov terraserver-usa.com
You must describe how you established the high ground water elevation:
Slope to West of property drops below base of SAS. Property elv= 50. Accessed local Groundwater
Contour and Topo Mapping. Ground water at approx. elv= 15.
350oldoysterrd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
rrif I
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
t �Y DEPARTMENT OF ENVIRONMENTAL PROTECTION
U
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE`DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 350 Old Ovster Road
Cotuit, MA 02635 LA
Owner's Name:' Robert&Deborah Corcoran
Owner's Address:
Date of Inspection: August 22. 2007 .
Name of Inspector: (Please Print) Jaynes M. Ford
CompanyName:: James M.Ford
Mailing Address' P O.Box-49
Osterville,MA. 02655-0049
Telephone Number: —(508)862-9400
CERTIFI.CATION STATEMENT
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 DER
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system'
Passes
Conditionally Passes
eeds Further Evaluation b the Local A -`'
y Approving Autlaor'ty
ails w
V t wA+
Inspector's Signature: Dater AuPust 29 2007
The system inspector shall sub t a copy If this inspection report to the Approving Authority(Board o Health o'3
DEP)within.30 days of completing this inspection. If the system is a shared system or has a design:flo of.10,0 0_
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional of a of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and.the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form . 6/15/2000 page 1.
Page 2 of 11 .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 350 Old Ovster Road
Cotuit. MA
Owner: Robert&Deborah Corcoran
Date of Inspection: _August 22 2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements: If"not determined please
explain.
The septic tank is metal and over 20 years_old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available. .
ND explain:
Observation of sewage backup or break out or high static water level in the distribution,box due to broken'or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
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:
.2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -350 Old Oyster.Road
Cotuit, tLfA
Owner: Robert&Deborah Corcoran
Date.of Inspection: August 22. 2007
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 C1VIR 15.303(1)(b)that the
system is..not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. .
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free-from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is.equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
. CERTIFICATION (continued)
Property Address: 350 Old Oyster Road
Cotuit MA
Owner: Robert&Deborah Corcoran
Date of Inspection:. August 22 2007
D. System Failure Criteria applicable to all systems:
You must indica
te either es or
Y 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 P or— g ondin of ,P 8 t to the surface
of the ground or surface water
clogged SAS or.cesspool s due to an overloaded or.
✓ 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 'h 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 groundwater 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A. gg copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or mo
re of the above failure.criteria exist as
des
cribed
bed in 310 CMR 15.303 there
fore the system fails. The system owner should contact the Board of
Health to determine what will be'necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either:"yes or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
— _ the system is within 400 feet of a surface drinking water-supply
— the system is within 200 feet of a tributary to a surface drinking water supply..
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or 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 3.10 CMR
15.304: The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DIS
POSAL SYSTEM
N SP ECTION FORM
PART B
CHECKLIST
Property Address: 350 Old oyster Road
Cotuit MA
Owner: Robert&Deborah Corcoran
Date of Inspection: August 22. 2607
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(arid 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 (SASjon'the site has been determined based on:
Yes No
✓ _ 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(3)(b)).
5
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 350 Old Oyster Road
Cotuit MA
Owner: Robert&Deborah Corcoran'
Date of Inspection: August 22,2007
FLOW CONDITIONS
RESIDENTIAL -
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does'residence have a.garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readin
gs,s if available
a�l
g , (last 2 years usage d
g (gp )) Unavailable
Sump Pump(yes or no): No
Last dat
e of occupancy:Y• — Cur rently oc
p
ed
COMMERCIAVINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary,waste discharged to the Title S system(yes or no):
Water meter readings,if available:
Last date of occupancy/use;
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped in 2006-ner owner
Was system pumped as part of the inspection(yes or no): No
If yes, volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be.
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):.
Approximate age of all components;date installed(if known)and source of information:
Leach field added in 1997-ner as built card
Were sewage odors detected when arriving at the site(yes or no): 'No
6
Page 7 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 350 Old Ovster Road
Cotuit MA
Owner: Robert&Deborah:Corcoran
'Date of Inspection: August 22 2007
BUILDING SEWER(locate on site plan).
Depth below grade:
Materials of construction: _cast iron,_40.PVC other_(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 20"
Material of construction: ✓ concrete _metal _fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance.(yes or no):
certificate) (attach a copy of
Dimensions: _ 1000 ag 1•
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: . 30"
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffler 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.).
Tees were resent. The li uid level was even with the.outlet invert: There did not aR ear to be an si ns-ofleak e:
GREASE TRAP: None (locate on site plan)
Depth below grade:
'Material of construction: _concrete _metal fiberglass(explain): _polyethylene other
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _350.01d Ovster Road
Cotuit MA
Owner: Robert&Deborah Corcoran
Date of Inspection: August 22 2007
TIGHT or HOLDING TANK: None (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: allons/day
Alarm present(yes or no);
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION.BOX: 1(2) (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even.
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
No solids were present. The li uid was at a normal level.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,,condition of pumps and appurtenances,etc.):
8
Page 9 of 11 .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: - 350 Old Oyster Road
Cotuit MA
Owner: Robert&Deborah Corcoran
Date of Inspection: August 22 2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation-not required)
If.SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6' 1000 al.
leachingchambers number:ber: _
leaching"galleries,number:
✓ leaching trenches,number,"length: —2-30'trenches(per as built card)
leaching fields,number,dimensions:
overflow cesspool,number:
- Innovative/alternative system Type/name of technology:
Commments(note condition of soil,signs of hydraulic failure,level ofpondin
The pit was drg,_damp soil,condition of vegetation, etc.):
The bottom to rade was 8'. A video camera was-used to ins am the leach trench. (here did not a "ear to be
any signs offadure.
CESSPOOLS: . None (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 or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.);
PRI ' I
VY: None (locate on site plan) -
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ondin condition P g, of vegetation,
g ion,etc.
I
Page 10 of.11
OFFICIAL INSPECTION FORM e NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .350'O1d 6 ster Road .
Cotuit MA
Owner:
Robert&D eborah C r oc oran
Dated Inspection: August 22. 2007
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.
I
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10
t Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 350 Old Oyster Road
Cotuit. MA- -
Owner: .Robert&Deborah Corcoran
Date of Inspection: August 22, 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground eater 40 +/ feet
Please indicate
(check)all metho
ds s ed _
to determine
rim ne the high ground water elevation.
Obtained from system design plans on record If checked,date.of design plan reviewed:
Observed site(abutting proper h/obsery anon hole wit
hin 150 feet of SAS)
✓ Checked with local Board of Health-explain:_ Topographic and water contours mans
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:-
You,must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours mans' the mans were showingapproximately 40'+/ to Around water at this
site.
i .
This report has been prepared only for the septic system.and components described herein. This septic system has been
inspected and passed as of the date of inspection.'This report is not a warranty or guarantee that the system will
function properly in the future..There have been no warranties or guarantees, either expressed,written or implied,
relating to the septic system,.the inspection, this report and/or any components of the septic system which have not
been located and.inspected.
• 11
1HE Town of Barnstable
OF t�
Regulatory Services
STABLE. ; Thomas F. Geiler,Director
MASS.
9� 1639 Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report;this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
TOWN OF BARNSTABLE
LOCATION 3 S-Q C� ���S �- ` Q ti SEWAGE#
VILLAGE � �'�' ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
L..-cdCC V -+r .®
LEACHING FACILITY:(type) I.ce r. `C��,� (size) 3 Ir'.* k a '
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -'3 (0 Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY R
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O a � ����Ay 3,a� �3 ,
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OWN OF BARNSTABLE
LOCATION 3 J 0 0/1 oy srev lz SEWAGE# '
, VILLAGE C C rt , ASSESSOR'S MAP&PARCEL Oaa• !��
INSTALLERS NAME&PHONE NO.
j SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) a- 30' 1 CA + (size) /CW P--I
NO,OF BEDROOMS 3
OWNER C o rC omn
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY ?, P0A-)
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TOWN OF BARNSTABLE
SEWAGE # _
VILLAG ASSESSOR'S.MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY f�'
li LEACHING FACILITY: (type)
NO.OF BEDROOMS
BUILDER OR OWNER 14--V
PERMIT DATE: �'3 �� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
Y
a
V_
,3 - -
No.
q Fee _
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppYication for Mi!5ponl *p5tem Construction 3Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System O Individual Components
Location Address or�Lot
�No.
�Q �+ ] /'�. Owner's Name,Add ss and Tel.No.
A s ors Map7P�c81 1 J 1�e.eb � vim/ (/
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow - 0 gallons per day. Calculated daily flow gallons.
Plan Date . Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alteration (Answer whe plic� sly-
)— czS - c3
Date last inspected:
Agreement:
The undersigned agrees toe a the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisio s of Tit 5 of the Envi mental Code and not to place the system in operation until a Certifi-
cate of Compliance has been isstil,�isd of lth.
Signed Date Z`3'
Application Approved by q0r.44 4 Date
Application Disapproved for the foYowingreasons
r
Permit No. 7- a Date Issued v
cJ
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
ZIppzication for nigogal *pgtem Construction Permit
Application for a Permit to Construct( )Repair((,<pgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. a Owner's Name,Add ess and Tel.No.
Assessor's Map/Parcel Cky.�
Installer's Name,Address,and Tel.No. ' Designer's Name,Address and Tel.No.
to
Type of Building
Dwelling fr No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day, Calculated daily flow gallons.
Plan Date . Number of sheets Revision Date
Title Y
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alteratio (Answer whei applicable)
Date last inspected:
Agreement:.,.
The undersigned agrees to ensure the construction and ma nte4ance of the afore described on-site sewage disposal system
in accordance with the provisiork�s of Title 5 of the Env' menta &de and not toy place the system in operation until a Certifi-
cate of Compliance has,been issutd by t tis 'oazd of lth.
Signed ^' - Date Z"3' !2Z
Application Approved by t2e.44Date ( -
Application Disapproved for the fRowing reasons \1
Permit No. 7 Date,Issued s
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
i
Certificate of Compliance
THIS IS TO CERTIFY,that the O site Sewage Disposal System Constructed.( Lj-fte—p—aired ( )Upgraded( )
Abandoned( )by % 6/?/j
at K) 141 eE' i ?'4" has been constructed in accordance
f with the provisions of Title 5 and the for Disposal System Construction Permit No. 7_ 2-- dated
Installer Designer
The issuance of this pe it shall not be construed as a guarantee that the system wil function as designed.
Date L' Inspector t
———q —————— ———— ———-———-———-————————
No. /
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Di5po.5al *p,5tem Construction Permit
Permission is hereby granted to Construct(--j Repair( )Upgrade( )Abando�6'
)
System located at U d/� ,e
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. 1
Date: Z 3 7 Approved by
s
a
y 4i
NOTICE:_This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT ()YITHOUT DESIGNED PLANS)
I, 0 hereby certify that the application for disposal works
construction permit signed by me dated2 / L_, concerning the
property located at 5 meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : 12 DATE: . 3
LICENSED SE IC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted]. `
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TOWN OF BARNSTABLE
LOCATIQN 3Sy 'l SEWAGE #
VILLAGE )r. J4—v t -�— ASSESSOR'S MAP& LOT 011- YI46
AL INST >LER'S NAME&PHONE NO. —
SEPTIC TANK CAPACITY /w G
LEACHING FACILITY: (type)
NO.OF BEDROOMS
BUILDER:OR OWNER.'
PERMTT.:DA'M- '3 e�' COMPLIANCE DATE:
Separation:Distance Between the:
Maximum:Adjusted Groundwater Table and Bottom of Leaching Facility Feet '
Private%*':Supply Well and Leaching Facility (If any wells exist
on site oR within 200 feet of leaching facility) Feet
Edge of.Wetland and Leaching Facility(If any wetlands exist
within 300.feet of leaching facility) Feet
Furnished,by..
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........ .. ...........................OF..........................................-----------------......._..__......--------•---.
for Disposal ,arks Tonstrnrttun rrmit
Application is hereby made for a Permit to Construct (A) or Repair ( ) an. Individual Sewage Disposal
System.at:
Loca6to Addressl��. y. No.
�e t_._..A�w ?�1 lf.!...f &:...
..--•----•...............................
O ner ---••...........................Address
Installer Address
Type,of Building Size Lot.._._. y � Sq. feet
Dwelling—No. of Bedrooms......--...........................Expansion ttic ( ) Garbage Grinder ( )
Other—T e of Building No, of persons__... .............. Showers , } — Cafeteria
W 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---.....................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
GTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:4 ---•--------------------------------------------••----------------------•-•----••--•---•------------.........................................................
0 Description of Soil........................................................................................................................................................................
x
x ..................... --------------------...........................................................................----------------...........................
UNature of Repairs or Alterations—Answer when applicable.__.............................................................................................
-----------------------------------•------•-------•----------------------------------•--.......-------------------------------------•------------------•-•------.................:.....----._.....----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT=% 5 of'the State Sanitary 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....................... - -
- - ate .
Application Approved By.. ....... - - .........••.. ...............:. :......... �$�
------•---•.....••-• -- ---. .....
Date
Application Disapproved for the following reasons:.................................... .......
..............................................................
----------------------------
•......
•......
... ----------------••••---------
--------------------
••--------------------------------------
-----
•.............................
-••-••---------
-------
-------
-----
-
Date
Permit No.---�,�---/Y..... Issued_./� <— � v..............
Date
✓�....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............................---------...O F....................
ApplirFa#ion for Disposal Works Tontrurtion rranit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
..........� .....®.�. ....a(...TEQ •�C v. LaT�'J CG17t//T
.............. ....._....._.. ........_.. .._.........................
oca Ad ress No
..................... .........Z ........ ..........t..........................................
Address
,� /`�!/�Q /•.-� --------------------------------•-- ------•--------------.....--.........--------...------------...
� Installer Address ���^��
d Type of Building Size Lot............................Sq. feet
U �Dwelling—No. of Bedrooms.......................................................... .Expansion ttic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons....._ ..................... Showers — Cafeteria ( )
Otherfixtures ..................................................•.................................................................
-------------------------
W Design 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.
Seepage Pit No---_---------------- Diameter.................... Depth below inlet.............-...... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by......................................................................... Date........................................
,� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------..........
•---------•----.------------- ...........-.--.-_ --------------
•-------
•-•---.......... -----------
0 Description of Soil........................................................................................................................................................................
x
U ---------------•-----------.....----------...---...••--•••-•-------•-....-----------...-•-••••------•-....----------.......••--------------•---•-----------......•--..._..._....---•----.........•-----.
w
x --------------------------------•-----------------------------------------------------------------------•--------•---------------------------------------------------------••--••--------------••--_....
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 TITLZ 5 of the State Sanitary 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......................-•--: - - -.--------------
•--------------
-------------
•----------
--------
ate r
Application Approved By �''`r-- t! r'!y r...... ........... ...... ........................ ' .7'
Date
Application Disapproved for the following reasons:...............................•--.............................................................._.__......_.._
...--•-••-•---•-----•...........................•---------......-•---.......----....----•-••-•----.----..._....-....-----•--------------------------.._..-----------------•----•-----•---•-•----••--•----
r-
Permit No.__. . ±���... -. Issued_ ._. .._��._a�......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................OF.... ...................... ...... .... -'L ..........................
Turdif irate of TompliFanrr
THIS I C TLEY, ThatIthe I div' ual wage Disposal System constructed ( ) or Repaired ( )
i �G
/2' �G.`� Instal
at ................................... —1-0.----...--•--------------------------------------------Z-----•------------....-----------------------•---...-••-••......-•--......
has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Co e s de rib the
application for Disposal Works Construction Permit No.. /_}__._ ../�_.... dated-._._; 1 ._. - �........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO RUE® AS A GUARANTEE THAT THE
SYSTEM WILL P NCTION ATISFACTORY.
DATE. e� --•-•----•-------•------------ Inspector- -----------•--- .......... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............OF....... ........................ FE
Dispusaa1 r � �n�u� to rrJ tt
/ / �� �
Permission is hereby granted............................... .................. ......
to Construct or R�e iaiTr ( ) an Individual ew ge Diss salt Rvstem �y
at No.------ ....... - �� T¢! . Y.....--•-1-/%'!'�� ....A&.-•-•-
..... ........
Street �S
as shown on the application for Disposal Works Construction P t No 9 .._ ated - /------------ ..--.--....................
. .�----- -------- ---
Board of ealsI- th
DATE........ .......... ....----.j�--...1...........................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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LGCATION c, C,wex, R-D , SEWAGE #
VILLAGE 7 &W ASSESSOR'S MA' P & LOT
INSTALLER'S NAME PHONE NO. CAk
SEPTIC TANK CAPACITY
LEACEiING FACILITYs(CyPe), �i��size)
NO. OF BEDROOMSPRIV.ATE WELL OR PUBLIC WATER .T`�1�✓C
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DATE PERMIT ISSUED: ! ^ �
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes - No
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