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HomeMy WebLinkAbout1166 OLD POST ROAD (CT & MM) - Health l�lo old o,sf' Road Cur�- , • a OG& 005 Commonwealth of Massachusetts IFF. i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1166 Old Post Road o Property Address Delores McLaughlin Owner Owner's Name .X; information is req u i red for every Cotuit ✓ MA 9-21-18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. `\`1�pttlNHn•Ipi�i� i Important:When filling out forms A. Inspector Information �. �y on the computer. � use only the tab James D.Sears JAMES m key to move your Name of Inspector cursor-do not = SEARS -+ Capewide Enterprisesuse key.the rEturn Company Name A T I f 153 Commercial Street �''��,F 5 INS?� IL�I Company Address Mashpee MA 02649 Clty/Town State Zip Code n�+ 508.477-8877 S1623 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 1 have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails r 9.22-18 ctor'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 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.7t2E/2018 Title 6 official Inspection form:Subsurface Sewage Disposal System•Page 1 of 18 i I• a5ed xe� dH 69:60 91.0Z 9Z d@S I Commonwealth of Massachusetts Title 5 official Inspection Form 'j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 1166 Old Post Road Property Address Delores McLaughlin Owner Owner's Name information is required for every Cotuit MA 9-21-18 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: The system is a 1500 Gal.Tank D Box and four Chamber's 2) System Conditionally Passes: i ❑ 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 ex9tration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. `A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc rev.7126/2018 Title 5 Official.nspeclion Form:Subsurface Sewage Disposal System-Page 2 of 18 abed xeJ dH 69:60 g 60Z gZ d@S i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1166 Old Post Road Property Address Delores McLaughlin Owner Owners Name information equiretio re Cotuit MA 9-21-18 required For every page. cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box, System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t,9nsp.doo•rev.712012016 Title 5 Of6dal Inspeckn Form:Subsurface Sewage MsKsal System•Page 3 of 10 6 a5ed xe� dH 6q:60 960Z 9Z daS Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1166 Old Post Road Property Address Delores McLaughlin Owner Owners Name information is Cotun MA 9-21-18 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.712612018 Tille 5Official inspeebw Forth:Subsurface Sewage Disposal System-Page d of 18 t, a5ed xe:1 dH 69:60 860Z 9Z daS Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T11 1166 Old Post Road Property Address Delores McLaughlin Owner Owners Name information is required for every Cotuit MA 9-21-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 4111111111IRM is less than 6" below invert or available volume is less than%day flow 4 FA►NING ❑ ® 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 wafer 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 400 feet of a surface drinking water supply ❑ the system is within 200 feet of a tributary to a surface drinking water supply III the system is located in a nitr en sensitive area Interim Wellhead Protection ❑ ❑ y og ( Area— IWPA)or a mapped Zone 11 of a public water supply well tWsp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurraoe Sewage Disposal System-.Page s of 18 5 a5ed xed dH 69:60 9l,0Z 92 daS Commonwealth of Massachusetts 3 Title 5 Official Inspection Form 'kv�wtl- Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 1166 Old Post Road Property Address Delores McLaughlin Owner Owner's Name information is required for every Cotuit MA 9-21-18 page. City[Town 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 NIA) ® ❑ 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)] 15insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of ti8 9 a5ed xez! dH 65:60 860Z gZ d@S Commonwealth of Massachusetts Title 5 Official Inspection Form pI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 1166 Old Post Road Property Address Delores McLaughlin Owner Owner's Name information is required for every Cotuit MA 9-21-18 page. cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2016-95,000Gals g ( y g (gpd}): 2017-85,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7!28r2018 Title 5 Official Inspection Form:Subsudace Sewage Disposal System-Page 7of 18 L abed xed dH 00:06 860Z 9Z d@S Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v � 1166 Old Post Road Property Address Delores McLaughlin Caner Owner's Name information is Cotuit MA 9-21-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personstsq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA 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!2612018 Title 5 Official Inspee6on Form:Subsurface Sewage Disposal System-Page 8 of 18 9 abed xed dH 00:06 860Z 9Z d@S Commonwealth of Massachusetts _ r Title 5 Official Inspection Form 'w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1166 Old Post Road Property Address Delores McLaughlin Owner Owner's Name information is required for every Cotuit MA 9-21-18 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: 1997 Permit # 97-384. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 42" 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.): Pipeing is 4" PVC SCH-40. t*sp.doc-rev.7/26/2018 7Ale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 6 abed xed dH 60:06 81.0Z 9E daS Commonwealth of Massachusetts F Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1166 Old Post Road Property Address Delores McLaughlin Owner Owner's Name information Is required for every Cotuit MA 9-21-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 32"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: 1500 Gal, Precast H-10 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 1„ Distance from top of scum to top of outlet tee or baffle a ll Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-Tape _Sludge Judge 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 at working level. Tank at 32"below grade wlboth covers at 14". In and outlet tee's. No sign of leakage or over loading, l5insp.doc•rev.7i2612016 Tille 5 Olfidel Inspection Form:Subsurface Sewage Diepoaal 5yslem•Page 10 of 18 of a5ed xeJ dH I.0:0l, 860Z 9Z daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1166 Old Post Road j Property Address Delores McLaughlin Owner Owner's Name information is required for every Cotuit MA 9-21-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont_) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 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 ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.MOM Title 5 Offioial inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 66 abed xed dH l•0:0l, 860Z 9Z d@S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 1166 Old Post Road Property Address _Delores McLaughlin Owner Owners Name information is required for every Cotuit MA 9-21-18 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cant.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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 is 16"x16"-30" below grade w/one line. Box is clean and solid. No sign of over loading or solid carry over. 151nsp.doc•rev.726=18 Title 5 Official Inspeclion Forth:Subsurface Sewage Dispose[Sysmm-Page 12 of 18 Zi, abed xed dH M06 960Z 9Z daS Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1;= 1166 Old Post Road Property Address Delores McLaughlin Owner Owner's Name information is Cotuit MA 9-21-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " 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: ® leaching chambers number: 4 ❑ Teaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: tSinsp.doc•rev.7128/2018 7"rlle 5 Official.nspection Form:Subsurface Sewage Dispoaal System•Page 13 of 18 £[ abed xed dH Z0:0 6 9[02 9Z daS Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments I � 1166 Old Post Road Property Address Delores McLaughlin Owner Owner's Name information is Cotuit MA 9-21-18 required for every 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.): Leaching is four infiltrators.Ck D Box and camera out line. No sign of over loading or solid carry over. No sign of holding water. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan); Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15insp.doc-rev.7,2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 b I, abed xed dH 20:0l, 9 60Z 92 d@S I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 1166 Old Post Road Property Address Delores McLaughlin Owner Owner's Name information is COW it MA 9-21-18 required for every page. CitylTown State Zip Code Date cf Inspection D. System Information (cant.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126W 8 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 g t a5ed xe:1 dH £0:01, 81,0Z 9Z d@S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1166 Old Post Road Property Address Delores McLaughlin Owner Owners Name information is Cotuit MA 9-21-18 required for every 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, includirig 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 e N o Nr p -� = � 9 „ (3 , tsnsp.doc•rev.7)26f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of a g 6 abed xe:1 dH £0:0 6 9I.0Z 9Z d@S I cam, Commonwealth of Massachusetts Title 5 Official Inspection Form IVSubsurface Sewage Disposal System Forth -Not for Voluntary Assessments 1166 Old Post Road L Property Address Delores McLaughlin Owner Owner's Name information is Cctuit MA 9-21-18 required for every page. Cityrrown state Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed $ Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg, 16 or attached For 15: Explanation of estimated depth to high groundwater included /?/I-). f 5nsp.doc rev.712612018 7RIe 5 Official Inspection Form:Subsurface sewage Disposal System•Page 18 of 18 LI, a5ed xezI dH £0:06 81.0Z 9Z daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rf 1166 Old Post Road Property Address Delores McLaughlin Owner Owners Name information is Cotuit MA 9-21-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No 10, Estimated depth to Me ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ® Observed site(abutting propertylobservation 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: Auger T.H. 10' no G.W.. Bottom of chamber's at 4' below grade. Bottom of chamber's at 6'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.7l2612018 Title 5 ofricial Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 86 a5ed xe,i dH M06 860E 9Z d@S COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 1166 OLDPOST RD COTUIT o C_)�D • 00 CA L` Name of Owner SKULTE N Address of Owner: 1166 OLDPOST RD COTUIT Date of Inspection: 8/30199 S`�A two Name of Inspector:(Please Print)n/a I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) ko O Company Name: n/ac��g� 11199- Mailing Address: n/a y Telephone Number: n/a CERTIFICATION 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 inspection.The inspection was performed based on my training and experience in the proper function and + maintenance of on-site sewage disposal systems.The system: X Passes The Inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs FurtherJEation By the Local Approving Authority performing at the time of the inspection.My Inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:8/30/99 The System Inspector shall a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS SYSTEM PASSES TITLE V INSPECTION RECOMMEND PUMPING EVERY TWO YEARS revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8/30/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nta One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n1a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken settled or uneven distribution box.The system will ass inspection if with approval of the Board of Health). Y P P ( PP ) broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced Wa The system required pumping more than four 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8/30/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n(a-(approximation not valid). 3) OTHER n/A revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8/30/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 tr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8/30/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)J X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8130199 FLOW CONDITIONS RESIDENTIAL: Design flow:,W g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):nLa Total DESIGN flow: 1111 Number of current residents:.1 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): YES If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):_NQ Water meter readings,if available(last two year's usage(gpd): D& Sump Pump(yes or no): NO Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: E& Design flow: n&gpd(Based on 15.203) Basis of design flow: n/a Grease trap present:(yes or no):11,12 Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n& Last date of occupancy: nLa OTHER: (Describe) nLa Last date of occupancy: n(a GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):NQ If yes,volume pumped n1A_ gallons Reason for pumping: Wit TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: Wa APPROXIMATE AGE of all components,date installed(if known)and source of information: 1997 Sewage odors detected when arriving at the site:(yes or no): NQ revised 912/98 Page 6 of 11 1. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8/30199 BUILDING SEWER: (Locate on site plan) Depth below grade: 26_ Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: _ (locate on site plan) Depth below grade: nLa Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQQ Dimensions: n(a G boo �1 G A`�'" \� Sludge depth: n& Distance from top of sludge to bottom of outlet tee or baffle: n& Scum thickness:jiLa Distance from top of scum to top of outlet tee or baffle:-wht Distance from bottom of scum to bottom of outlet tee or baffle: n& How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Sept it system and all components are structurally sound.Recommend pumping system two years for maintenance GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: n& Scum thickness: nla Distance from top of scum to top of outlet tee or baffle:jVi Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: Wit Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nLa revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8/30/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/A Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n& Dimensions: Wa Capacity: Wa gallons Design flow: Wa gallons/day Alarm present: NO Alarm level:-nLa- Alarm in working order:Yes—No—: NO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) . D-Box is structurally sound and functioning nronerly PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): 1)(O Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I , SYSTEM INFORMATION(continued) Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8/30/99 SOIL ABSORPTION SYSTEM(SAS): _ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n1a Type: leaching pits,number: Wit- leaching chambers,number: -nLa leaching galleries,number: .n(a leaching trenches,number,length: n1A leaching fields,number,dimensions: nLa overflow cesspool,number: n& Alternative system: nLa Name of Technology: -n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) SAS APPEARS TO BE FUNCTIONING PROPERLY-SYSTEM SHOWS NO SIGNS OF FAILURE CESSPOOLS: _ (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: nLa Depth of solids layer: Wa Depth of scum layer. n& Dimensions of cesspool: nLa Materials of construction: Wa Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)n/A Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:n& Depth of solids: nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8/30/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a A p (A 6 Dc R� 1 Sie AA 00 �� In6 gc 97 . revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1166 OLDPOST RD COTUIT Owner: SKULTE Date of Inspection:8/30/99 NRCS Report name: nta Soil Type: n& Typical depth to groundwater: n& USGS Date website visited: n& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate X Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater n/a Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAP AND CHARTS revised 9/2/98 Page 11 of 11 . ^ FB T LE � LOG ` 1 " SEWAGE # ,9C ,._. C� VILLAGE ASSESSOR'S &P!-L6T'�C1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 Ah 43 ggS� c Jd �B LPc TOWN OF BARNSTABLE- �� . �� . LOCATION e ®ko o"o SEWAGE# �- VILLACIE M= •r ASSE qjrs MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITYZ , LEACHING FACILITY: (type) 4 � ^`(-� (size) NO.OF BEDROOMS a BUILDER OR OWNER 4 PERMTTDATE: :7 :.3© COMPLIANCE DATE: Separation bistance Between the: 1. 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 !r � 1 Y � r" t. r � r No. 7 s3 1 7 Fee S-40 THE COMMONWEALTH OF MASSACHUSETT - Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zippfication for Xh6pont *pztem Comaruction Vermit Application for a Permit to Construct( )Repair(L-4upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.I l 6� (5 K, Owner's Name,Address and Tel.No Assessor's Map/Parcel cb r T 1,� Pw V✓ 0 !Q . 007, Installer's e,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 _3W gallons per day. Calculated daily flow C5 gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank I S Type of S.A.S. A'cc, C� Description of Soil s Aoo Nature of Repairs or Alterations(Answer when applicable) �v ) S \ c L < CT d Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i is Signed 4A Date Application Approved by Date '2_?Q —0 Application Disapproved for the ollowing reasons Permit No. -7— Date Issued 7 3 C No. 3 0 7 � �� �% £ t Fee S—Q " THE COMMONWEALTH OF MASSACHUSETTS-=- Entered in computer: L..,Z q Yes - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS S 0[ppfication for �Nopool *pgtem Conotruction Permit Application for a Permit to Construct( )Repair(I/�pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 6 6 ® Owner's Name,Add ss and Tel.No. Assessor's Map/Parcel C6 ry T okt_ >/ Installer's 15Ane,Address,and Tel.No. Designer's Name,Address and Tel.No. ( (4 Type of Building: Dwelling No.of Bedrooms 3 Jl+ Lot Size \ sq.ft. Garbage Grinder( ) Other Type of Building "� No. of Persons Showers( ) Cafeteria( ) Other Fixtures 1 G Design Flow �� gallons.per day. Calculated daily flow _V 'A t gallons. Plan Date ` Number of sheets r Revision Date Title _ Size of Septic Tank Type of S.A.S. F %-V' Ck 0t:t7 Zt-�K-18r V� Description of Soil a\`e oJAob Nature of Repairs or Alteratio s(Answer when applicable) F Date last inspected: Agreement: a . - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place.the system in operation until a Certi for ry; cate of Compliance has been' s . Signed Date -7- 7 Application Approved by / Date Application Disapproved for the following reasons / Permit No. 7- S.;- Date Issued 2 3 b ----- - --------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTI t t n-site D`sposaal System Constructed ( )Repaired ( )Upgraded Abandoned( )by a C Y3� at 166 0 1 Z o51 An has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 7 r 1 y dated f' 7 3U Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 7 �/'! 1 Inspector i --------------------------------------- No. 3 de Fee 5� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwi.gpoaf bpotem Construction Permit Permission is hereby granted to Construct( )Repair(1/�pgrade( )Abandon( ) System located at 1 0(D ►n6ST 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! �( E t Provided:Construction must be completed within three years of the date of this permit. Date: _�U —% Ap p rove by' �ff�F-i'�i I C i ?t f�J a S NOTICE: This Form is to be used for.. the Repair of Failed Sep& Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated --7—�;n concerning the property located at \Wa Ot Q meets all of the i I 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 �WZ;Z� �(� • 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 : DATE: SY LICENSED SEPT STEM 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]. 1�-�"� � � . '� � t .� �� ��v f -� O�' � � w. i TOWN OF BARNSTABLE LOCATION O ko P SEWAGE # 7- VII,LAGE U 1 r AS 0 'S MAP & LOT - OD INSTALLER'S NAME&PHONE NO. y SEPTIC:TANK CAPACITY �� i LEACHING.FACILITY: (type) �F,,�,)r1 ;T .:. , (size) j NO.OF-BEDROOMS BUILDER OR OWNER 1 � PERMTTDATE: '7 0 'q COMPLIANCE DATE; Separation Distance Between the: t 1 Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water-Supply Well and Leaching Facility (If any wells exist Feet on site.or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished.by . d � R A 4. :-IrQ ; 3 33