HomeMy WebLinkAbout1174 OLD POST ROAD (CT & MM) - Health 1174 OLD POST RC4 COTU',T
A =
i
I
i�
a
J
r ��
i
t
..! _
F.
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 s DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
'Property Address: 1174 OLD POST RD. COTUIT MAP 056 PAR 008 L 2&5
Name of Owner SEGGOS -
Address of Owner: SAME
chi
Date of Inspection: 10/11/99 ~ `'r+C1 VE0
Name of Inspector:(Please Print)JOHN GRACI ,O CT
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) ` '� .. 2 2 1999
Company Name: n/aHE
�� ' NOFggR
Mailing Address: n/a AlDpO �tE
Telephone Number: n/a
f T-1 g
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 Further Evaluation 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:10/12/99
The System Inspector shall submit 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 R
THE SYSTEM PASSES TITLE V.INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFULL LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1174 OLD POST RD.COTUIT MAP 056 PAR 008 L 2&6
Owner: SEGGOS
Date of Inspection:10/11/99
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 15.3 are indicated below. 03exist.Any failure criteria not evaluated
COMMENTS:
System passes Title V inspection
B. SYSTEM-CONDITIONALLY PASSES:
n[a 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.
nta 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.
DLit 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 pass Inspection if(with approval of the Board of Health).
_ broken pipe(sj are replaced
_ obstruction is removed
_ distribution box is levelled or replaced
Y q pumping y
DLit The system requiredmore 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
A
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1174 OLD POST RD.COTUIT MAP 066 PAR 008 L 2$5. _ F
Owner: SEGGOS
Date of Inspection:10/11/99
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
and the environment. is failing to protect the public health,safety
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.
4 .
2) SYSTEM WILL FAIL UNLESS THE BOARDOF 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 II(er(approximation not valid).
3) OTHER
n1a
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1174 OLD POST RD.COTUIT MAP 066 PAR 008 L 2&6
Owner: SEGGOS
Date of Inspection:10/11/99
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 31.0 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 n[a.
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. ry
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, j
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to largesystems 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
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1174 OLD POST RD.COTUIT MAP 066 PAR 008 L 2&6
Owner: SEGGOS
Date of Inspection:10/11/99
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)
11 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on thetproper maintenance of
SubSurface Disposal Systems.
revised 9/2/98
Page 5.of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1174 OLD POST RD.COTUIT MAP 056 PAR 008 L 2&5
Owner: SEGGOS
Date of Inspection:10/11/99
RESIDENTIAL: FLOW CONDITIONS
Design flow:_M g.p.d./bedroom
Number of bedrooms(design): _ Number of bedrooms(actual):
Total DESIGN flow: IV
Number of current residents:Q
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NQ If yes,separate inspection required .
Laundry system inspected(yes or no):M
Seasonal use(yes or no):M
Water meter readings,if available(last two year's usage(gpd): Wa
Sump Pump(yes or no): MS!
Last date of occupancy: 6/1/99 r.
QQMMERCIAI/IND STRIA
Type of establishment: n1a
Design flow: nta gpd(Based on 15.203)
Basis of design flow: ilia
Grease trap present:(yes or no):M
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Y
Water meter readings.if available:Wit
Last date of occupancy:
OTHER: (Describe)
n1a
Last date of occupancy: nta ,
GENERAL INFORMATION =
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NQ.If yes,volume pumped nLa_ gallons
Reason for pumping:
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., nLa
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1997 PERMIT 7 290
Sewage odors detected when arriving atthe site:(yes or no) NQ ,
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION(continued)
Property Address: 1174 OLD POST RD.COTUIT MAP 066 PAR 008 L 2&6
Owner: SEGGOS
Date of Inspection:10/11/99
TIGHT OR HOLDING TANK: N_Q (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan) `
Depth below grade: LiLa
Material of construction:_ concrete_ metal Fiberglass _Polyethylene_ other(explain)
Lila
Dimensions: nta
Capacity: nLa gallons
Design flow: Lila gallons/day `
Alarm present: NQ
Alarm level:jiLa- Alarm in working order:Yes_No_: X2
Date of previous pumping: n& f
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nta
DISTRIBUTION BOX: X '
(locate on site plan)
Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIP
Comments:.
(note if level and distribution is equal,evidence of solids,carryover,evidence of leakage into or out of box,etc.)'
'DISTRIBUTION BOX I STRII TIIRA I Y SOLND,SY4TFM IC Ftlni�TIONI"J �Ri rER�t
PUMP CHAMBER: NQ j
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
Lila
revised 912198 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1174 OLD POST RD.COTUIT MAP 066 PAR 008 L 2&6
Owner: SEGGOS
Date of Inspection:10/11/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa sy
Type:
leaching pits,number: n(a
leaching chambers,number: 3.RECHARGFRA
leaching galleries,number: _nta Y
leaching trenches,number,length: n(a
leaching fields,number,dimensions: nLa
overflow cesspool,number: n&
Alternative system: n(a
Name of Technology: -n& `
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation;etc.)
MESAS APPEARS TO RE F N TIONINf PROPERLY,SOIL IN LEACHING AREA n nRM
CESSPOOLS: _
(locate on site plan)
Number and configuration: Wa
Depth-top of liquid to inlet invert: n/H
Depth of solids layer: n/3
Depth of scum layer.
Dimensions of cesspool: nia
Materials of construction: iata
Indication of groundwater: n(a 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.)
nla
PRIVY:
(locate on site plan)
Materials of construction:n/A Dimensions:n(a
Depth of solids: n(A -
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/A
x
. w -
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property.Address: 1174 OLD POST RD.COTUIT MAP 066 PAR 008 L 2&6 {
Owner: SEGGOS
Date of Inspection:10/11/99
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
CAA'
A
h l3 s�
nc
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, -
PART C
SYSTEM INFORMATION(continued)
Property Address: 1174 OLD POST RD.COTUIT MAP 066 PAR 008 L 286
Owner: SEGGOS
Date of Inspection:10/11/99
NRCS Report name: nLa
Soil Type: Wa
Typical depth to groundwater: nLd
USGS Date website visited: nLd
Observation Wells checked: MQ
Groundwater depth:Shallow _ Moderate _ Deep
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record w
_ 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 MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
T?WN OF BARNSTABLE'
LOCATION � r>)J ,,��? Ro Ab SEWAGE # —
VILLAGE C I - _ ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE V M-A CO r-,
SEPTIC TANK CAPAC
LEACHING FACILITY: (type) TZ (,N A 2 F 2 (size) d�
NO.'OF BEDROOMS
BUILDER OR OWNER�1V Q xa
PERMTTDATE: p� y 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 F
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 fa ility) Feet
Furnished by t
vim
r s
/ /
,r �
e ` $ 50. 00
No. '' Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppliCotion for �Bigooal *pgtem Cow5truction i3Crmit
Application for a Permit to Construct( )Repair( )Upgrade(X4Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. 1174 Old Post Road Owner's Name,Address and Tel.No. Weinberg
Cotuit,Mass . 1174. Old POst Road
Assessor's Mao/Parcel C o t u i t,Mass .0 2 6 3 5
Installer's Name,Address,and Tel.No.5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville ,Mass . 02632 Box 66 CEnterville,Mass . 02632
Type of Building:
Dwelling XX-_5qNo.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder 11VO)
Other Type of Building R.ES No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 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
�'n+iii + canr�
Nature of Repairs or Alterations(Answer when applicable) Omitting c e s s 1p o o l s . Tnsta.11ing
1-1500 gallon septic tank: 1 -Distribution box: 3-333 cultec
rechargers packed in 3 . 5 ' of 1211 stone : Drip pipe withinthe chargers .
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 is-sued by this o d o Health.
Signed j Date 6/5/97
Application Approved by Date cl—xne�,
Application Disapproved for the following reasons
Permit No. Date Issued
' $ 50. 00
No. " -_7
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpprication for Migpaal *pttem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade(X�Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Post Road Owner's Name,Address and Tel.No. Weinberg
Cotuit,Mass . 1174 Old Post Road
Assessor's Map/Parcel C o tui t,Mass.0 2 63 5
Installer's Name,Address,and Tel.No.5 08—7 7 5—3 3 3 8 Desi ner's Name,Address and Tel.No.
J.P.Macomber & Son Inc. J.gP.Macomber & Son Inc.
Box 66 Centerville,Mass . 02632 Box 66 CEnterville,Mass . 02632
Type of Building:
Dwelling XXYNo.of Bedrooms I Lot Size sq.ft. Garbage Grinder(NO)
Other Type of Building RES No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank i�"' Type of S.A.S.
Description of Soil
Cotuit sand
Nature of Repairs or Alterations(Answer when applicable) Omitting cesspools. Installing
1-1500 gallon. septic tank: 1-Distribution box: 3-333 cultec
rec argerspa..e ® n 3. 5 ' of lilt s one: Drip pipe wit inthe chargers.
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 issu d by this 'l!od Health. 6 5 7
Signed '' /I> �G�� G� Date
Application Approve&by " ` Date
Application'Digapproved for the following reasons
Permit No. Date Issued
�. THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded'6XX)X
Abandoned( )by J.P.Macomber & Son -Inc.
at 1 174 Old Post Road Cotuit has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. _ dated
Installer J.P.Macomber & Son Inc. Designer J.P. acorn er & Son Inc.
The issuance of this permit shall not be construed as a guarantee that the syste func i as designed.
Date - T Inspectorfj
f
---- ---------------------------- --
No.
Fee-
50- 00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
Mizpoml *p5tem Con$truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(XX)Abandon( )
Systemlocatedat1174 Old Post Road Cotuit
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 it.
Date: 140e—" e42 Approved b �''
CERTIFICATION Or SKE'I'Cll AND APPLICATION FOR A DISPL.,
WORKS CONSTRUCTION pc, ltn-ll'I' (WI'I'flOU'I' DESIGNED PLANS)
I J.P.Macomber Jr. _ l.,r;i c�:rtily th:[t tltc application for disposal works
construction pernut signed by I11C l!atk'. I 6/5/97 , concerning the
property located at 1174 Old Post Road Cotuit meets all of the
following criteria:
• There are no Nvetlands within 300 fcct of the proposed septic system
• There are no private wells within 15U feet of the proposed septic system
• The observed groundwater table ,s I Ice[yr greater below the bottom of the Ieaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE: 6/5/97
LICEN D SEPTIC SYS'fE,'yl li�S'1'ALLEIZ IN'1'l-i.E TOIYN OF BARNSTABLE NUMBER _
(Attach a sketch plan of the proposed s)sMu. Also if[Ile licensed installer posesses.a certified plot plan,
this plan should be submitted].
Front
1 -1500 gallon tank
0
1 -Distribution
box
f fr'3-330 Cultec rechargers
T7WN OF BARNSTABLE.
c•�
LOCATION d�� r �b SEWAGE it
VILLAGE ASSESSOR'S MAP & LOT u
INSTALLER'S NAME&PHONE N . Yl
SEPTIC:TANK CAPACt i d
LEACHING FACILITY: (type»l„ 23U (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: / -S : 7 . COMPLIANCE DATE:1
Separation Distance Between the:
} Feet
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet i
on site.or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
withihi-300 feet of leaching facility)
Furnished by
Q
1 �
fr, o11P sfTOWN OF BARNSTABLE
f -'L....
LOCH N 74 SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT 05 008,
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER '<
PERMTTDATE: 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
��
� a
ry � '• � / �
t \ /
� �� �•
�3
� �� �� �
/�
� �__
_._. .-.
�,
-�-'
0
P:,.
f
�.
i
.
PROPERTY ADDRESS: ��1174"`0Id Po DATE: , /14/97st Road
f' ✓
Cotuit,Mass . ( U
-02635
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 .- 2-6,x8l block cesspools.
Based bn my InRrK+ction, I certify the following conditions:
1 . This is not a title five septic system.
2. . This is a sewage system that is around 30 years old. +
3. Standing water is present in main cesspool. The house
has been vacant- for a period of time.
4. System has been filled to its capacity in the past.
5. Main cesspool has a broken cover and one block is
starting to roll -
0
:-Shout be uad pgred to a :SIGNATURE• Gil
-� title five septic system
Name: J. P.Macomber Jr...
Company: •P_Macor�ber & Son�_Inc ;
Address:--8eac-bb------=1-------
Centerville �Mass__02b32 '
Phone:___5118-2 .5-3338------- _, i
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
•
JOSEPH P. MACOMBER: & SON, INC.
Tanks-Ceupoois-LeachfIsIds
,Pumped & Installed
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
775-3338 775-6422
Commonwealth of Mossachusetts
ExecutNe Office of EnWonmental Affairs
Department of
Environmental Protection
William F.Weld t0..n« Trudy Cox.
Arpeo Paul GAuod a«+��r
LL Gw�rt+or David B. strum
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
p.rop.rty Addre.s 1174 Old Post Road C o t u i t,Mass . Addreas of owner.
Date of Inspection:5/14/9 7 (It different)
Namsoflaspector.JOSeph P.Macomber Jr.
Co J PT NaaoejAddrT agd Telephone Number.
MMacon er ��cc on Inc.
Box 66 Centerville ,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
I cart*that I have personally inspected the"wage disposal system at this address wad that the information reported below is true, a+ocerate
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 CA41 a sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
)feeds Further Evvalupa�tLOW�on By the LOW Approving Authority
ti' ,T/Fail
Inspector',8lgaaturx Date: , 7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
iarpection. 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 suhmis the
report to the appropriats regional otSoe of the Department of Environmental Protection.
The original should be sent to tha system owner rind copias sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY.
Check A. B, C, or D:
A) -SYSTEM PASSES:
I have not�Q_ found information which r►ul induates that the system violated say of the failure criteru►as deflaed is 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
, Vh One or more system components need to be nplaosd or repaired. Tha system,upon completion of the replaoeamnt or repair,Paned
inspection.
Indicate Yet, no,or not determined(Y,N,or ND). Doscrtle basis of determination in all Instances. It"not determined,explain why not)
The septic tank is metal,cm:ked,structurally unsound,shows subetoatial infiltration or uffitratio n,.or Oak failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)55&1049 a Telephone(617)292•MM
t�►mtad on wcWWd raps
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
Prop+rgAddre.s 1174 Old Post Road Cotuit,Mass .
Owns: Weinberg' --wL�
Date of In&pocttow 5/14/97
III SYSTEM CONDITIONALLY PASSES(continued)
A&&-, Sewage backup or breakout or bo atatk waw level observed in the distribution boa is due to brWma or ob4r utod pipet.;
or due to a broken,nettled or uneven dtArb4tlon bos. The gstam r►ia pea iarpicfinn if(with approval of the Board of
Heakh): .
broken pipe(&)are repl&o&d
obstruction Is removed
distrisutba box is livened or repLced
Al/ Tie V tam required pumping more than four tin►«&year duo to bsokao or obstr4ctW pipe(s). The systaa will pane
in&pecttoo If(with approval of the Board of H"hW:
broken pipe(&)are replaced
obomwlon is removed
C) FURTHER EVALUATION 18 REQUIRED BY THE BOARD OF HEALTHr
Alb Conditions east which require Author evaluation by the Board of Heakh in order to determine Ifths systam is Luling to proud the
publk health,safety and the savironmeat.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONM>i24M
Ceupool or privy is within 60 feet of&surLwe water
Cesspool or privy is within 60 feetbf a bordering vegetated wetland or a salt marsh.
3) SYSTM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF APPROPRIATE)
DETEBMDM THAT THE SYSTEM 13 FUNCTIONINO IN A HANKER THAT PROTECT THE PUBLIC EMAI.TH AND
SAFETY AND THE ENVIRONMEMI:
The ssstam has a septic tank and soil absorption system mad In within 100 Let to a surface water supply or utkstary to a
sur4a water supply.
The gvtam has a septk tank and&all absorption cysts=and is within&Zone I of a public avatar supply we.lL
400 The system has a septic tank and&oil#beosption system and is within 60 Get of a private water supply w*L
The system has a septk tank Lad*oil absorption gstam sad is Is"than 100 feet but 60 Get or more from a prresu wu.ar
supply w%A ualaw&well water analysis for coWorm bacteria and volatile wvuLk compounds indkates that the well is free
from pollution from that facility and the pressnce of ammonia nitrogen and nitrate nitrogen is equal to or lau than 6 ppm
3) OTHER
2-61x8t block cesspools . All no ' s to paragraph C '
Section
I
(rwlsed 11/03/95) 3
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(ooatlnued)
PropertyAddre" 1 174 Old Post Road Cotuit,Mass .
Owner. Weinberg
Date of Inspeotton:5/14/9 7
DJ ;, :;
aed that tha system violates one or more of the following falm Criteria as darned in 310 CUR 16.303. Tha basis for
miaation is Wmtisad below. The Board of Health should be contacted to detarmias what will be necessary to Correct the
Backup of&*wags late Ucility or system component due to an ww"ded or Clogged SAS or ce"pool
Discharge or poadia of aIDuent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
A/$C Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
Liquid depth in ceupool is Is"than 6'below invert or available voluma is less than V2 day flow.
Required pumping more than{limas in the last year&U duo to Clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,carpool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 60 test of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 60 rest from a private water supply wall with no
acceptable water quality analyeis. If the well has been analyzed to be acceptable,attach copy of well water aaabsis for
ooliform bacteria,volatile organic compounds,ammonla nitrogen and nitmts nitrogen.
El LARGE SYSTEM FAILS:
The foUcwing Criteria apply to large systems in addition to the criteria above:
AO The system server a facility with a design flow of 10,000 gpd or greater(Large System)sad the system is a Accideent threat to pubi
health and safety and the aavironment because one or more of the following conditions erdst:
the system is within 400 feet of a surface drinking watar supply
" the system is within 200 feet of a tributary to a surface drinking water supply
10 the system is located in a nitrogen sensitive area(Interim Wallhaad Protection Area(IWPA)or a mapped Zone II of a pubb
water supply wall)
The owner or operator of any such system shall bring the system and Udlity into NU Compl anos with the groundwater treatment program
roquiromeats:of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for Author information..
t1 . System has failed in past. Filled to'capacity and pumped. Covers were
'�raised .at this time.Blccks sh w saturation. One block rolling in. Y-
t (revised 11/03/95) _ ,W`,s .. - . ��b _ _ r _�, -�-��'•
2. resent sewage system should be upgraded to a title
L,f e v e septic system
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECIO.IST
P,npe,t,,dd,.,a1174 Old Post Road Cotuit,Mass.
Owner. Weinberg
Date of iaspeotion. 5/1 4/9 7 '
Cheek if the haw been done:
��/� information was requested of the owner,oocu c and Board n
, pea, of Health.
'one of the system components have been pumped for at least two weeks and the system has been reowvmg normal 1k w rata
&nzg that period. LrP volumes of water haw not been introduced into the system recently or sr part of this=pecw,
C 'As bulk plans have been obtained and examined. Note itE Y are not evail;bU-wlth NIA.
faplity or dwelling was inspected for sips of sewsp back-up.
br
system doer not receive aoa-sanitary or industrial waste Dow
77nUw she was ins for of breakout.
potted signs
f1A11 system components,A&diad the Soil Absorption System,have been located on the site.
WAOC The se�tank manholes wars uacpvered,op
ened.paned,and the interior of the septic teak was inspected for condition of baIDes or
tell,materiak of construction, diaunsions,depth of liquid,depth of sludge,depth of swm.
2The size and location of the Soil Absorption System on the sit*has been dsterminad based on uistin information or
cep tad by non-intrusive methods.
The facility owasr(and occupants, if different from owner)were provided with Information on the proper naaoe of Sub-
Surface Disposal System.
I
(revised 11/03/95) 4
r
C,5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddross: 1174 Old Post Road Cotuit
Owner. Weinberg
Date of Insp"tiow 5/14/97
FLOW CONDITIONS
RESIDENTIAL-
Design f1ow-_j2L_pljpnj •
Number of bedrooms IV
Number of current rw,idaatr.
Garbage pindar(yes or no):_4y)
Lauadr7 Connected to syetam(yw or no):3t s►
Seasonal use(yes or no):
Water meter readings,if available: 4Z o
Last date of oocupancy:f�&k
COMMERCIAL NDUSTRIAL•
Type of•stab' at::
Design flow:t/ llons/day
Grease trap present: (yes or now
Industrial Waste Holding Tank present: (yes or nohLA
Non-sanitary wasta discharged to th#Title b"tam: (yea or no)-
Water matsr readings, if av ble
Last data of oocupaacy:
OTHER:(Ducriba) k6
Lan date of occupancy: 1 _
GENERAL INFORMATION
PUMPING RECORDS and sourr of information:
/>IJ
sysum pumped as part of ins ion: (yes or no
If yes,volume pumped: y� ru
Reason for pumping:
TYPE OF SYSTEM
Septic taak/distribution b=Aoil absorption system
Single cesspool ,
Overflow cesspool
Privy
shared system(yes or no) (if yes, attach previous inspection records, if any)
497 Other(explain)
APPROXIMATE AGE of all Components, data inrtalled(if known)and sours of information:
I
Sewage,odOrs detected when arriving at the site: (yes or no)-
(revised 11/03/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: 1174 Old Post Road Cotuit,Mass .
Owner: Weinberg
Date of Inspection:5/14/97
SEPTIC TANK:&V&t?- e
(locate on site plan)
Depth below grade._A-4
Material of constructionYk.Lftoncrete _metal _FRP_other(explain)
yA
Dimensions:_ 44
Sludge depth.
Distance from top of sludge to bottom of outlet tee or baffle:,&-if
Scum thickness:_ _All
Distance from top of scum to top of outlet tee or baffle:,
Distance from bottom of scum to bottom of outlet tee or baffle.,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural
•rity, evidence of leakage, etc.)
e p i it
GREASE TRAP. N4V(,
(locate on site plan) y
Depth below grade:/(/,4-
Material of cons►mrti6r;N-eoncrete _metal _FRP_other(explain)
Dimensions; rV
Scum thickness:
Distance from top wt scum to top of outlet tee or bafile:j1h1—
Distance from bosom n) •rum t-honom of outlet tee or 6(Ue:_�(,1�
Comments:
(recommendation for pumping, condit-n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.1
rease trap is Rot present
(revised 1/15/9$) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
property Address: 1174 Old Post Road Cotuit,Mass/
OWMA Weinberg
Date of hwpeotton:5/14/97
TIGHT OR HOLDING TANK:� �
(locate as me plan)
Depth below grade: -.4
Material of •&&ncsete_-metal--M_othwuplaia) -
Dimeaaioas:
Capacity one
Design flow: day
Alarm level: i✓
Comments:
(condition of inlet toe,condition of alarm and float switch",etc.)
Tight or holing tanks are not present.
DISTRIBUTION BOX AtZM
(locate on site plan)
Depth of liquid level above outlet invert:
comments:
(note if level and distri ution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
Vistrioutlon
PUMP CHAMBER:,�QUQ.,
(locate on sits plan)
Pumps in worldne order.(Yes or no)—&261
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
ump c amber is no pre e
(revised 11/03/95) �;` • •°•;
SUBSURFACZ SEWA08 DISPOSAL SYSTEM INSPECTION FORS[
PART C
SYST8M INFORMATION(oacUnued)
Pmj,w Add,..s 1174 Old Post Road Cotuit,Mass .
Ow"n Weinberg
D.ta or LwPocu"5/14/97
son,ABsoRMON 9YB M(sA9 z
Go="oa sfta P144 if poodbu;auavation aot raquin4 but=q be apprazim W b7 aon4nbv.ty"huts)
•
If ua d.tarminad to be Pn"A aPUim.
Lachlai p4 aumbar.,,,�
L+eala j ehamba:s,number.
6"146s puerw IND—be :
l..c>IIM ti.ncaa.,numb.rlaa�th
)..cafe]e614 aumnar,dsm.Paioos l'-
�m -a" Pt w=b r
S a n C1: (;e s s O O 1 s s Pl Off/ kdmuua t` '1.w1 of poadia& 000ditian of yr scioLate.)
P signs that system has been fille o capaci y
All iringat.at., nn is nngma1 .
CESSPOOL93
(font oa stt.PIRA)
fiNamDar aad ooaIIyuratioa
D.pcb of liquid to(alac iavart
D.pch of.oMs lyar.
D•pd of mm lyar,
Dimaadoas of osarpook I
I6.tmi.l.of 00C.St vdioa
of poundw&Ur�e4, n�)1
Wow giig
(oaaspool must be pumpd u Part
comm.nts (note awAl ioa of•ofl.dps of kvdsulie UM I"of pondl&oonditioa of..g.e.don,etc,)
Same as Abovp
PRMI YA41e--
00ad on ait.Plea)
If.tari.l.of ooastrv�ian
D.pca a<soM&-.,(A_
CommaWx(wu condition Of 04 44as of 1pdraalio Uun,l•yl of pon&&oon&Lw%at r.p tation,Ste.)
rivy is not preSent
` v
(rwisod 11/03/95)• 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L'_SPOSAL SYSTEM:
include ties to at least two permanent references landmarks. or benchmarks
locate all wells within 100 '
Cotuit Water Company
428-2687
T5, TWO
DEPTH TO GROUNDWATER
201 + depth to groundwater
rgthod "of determination or approximati:om:
Tnstar ee `` �i Ys effi ' ' 0 d.� c3 t _R"a d,'C'otuit,.Nfass .
x�P r m; f- #9.5.-10 T 1 N obi,�.f ""��o�i� �t' ,..
1
•P.tt1T RtT�+—T�1t'.1. J.R•r.r.n/�Tna7rrin1lr.1++1.f.►t+.�*RAT/R'A7r l'�-'a�f1eT .TT-rrr•1r-Tn—:..--.r—
TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
F.•••T^t�T•'.•::f_T.t I7�.TTT1A'[T.11t•1I.•f1rI T!{TlC�1►!TR}T,T—[•I T'TVTRlr•fR7f.�TwRtlArt�}�7 �
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 1174 Old Post Road Cotuit,Mass . '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER's NAME Weinberg •
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Sa'if 'Inca
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State Lip
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (790 1 1578-
CERTLFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate , and
complete as of the time of The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experien6e in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
Systeui PASSED :
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15. 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
<XXXXXXXX�Sys tem FAILED*�
The inspection which I have con acted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15t303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature 5/14/97
Date
One copy of this rtification must be provided to the OWNER, the BUYER
applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or""operator shall upgrade
he aYste
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 Ch1R 15 . 305 .
par td .doc
r
� * G
W
to �U
SbyY 3r�1
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title `
CERTIFIED TITLE 5 SYSTEM INSPECTOR ,
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ' ton of Water Pollution Control