HomeMy WebLinkAbout0134 OXFORD DRIVE - Health 134 OXFORD DRIVE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�y
6..`e 134 Oxford Dr.
Property Address
h
Milles -
Owner information Owner's Name
everyage.ed r Cotuit MA 02635 5/1/18
every page.
City/Town State Zip Code Date of Inspection ^„
0
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.
A. General Information
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
CitylTown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a.DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5/1/18
Inspecto 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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the•system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Forme
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
everyage.ed r Cotuit MA 02635 5/1/18
every page.
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,'not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Il
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
e reqevery
page.
Cotuit MA 02635 5/1/18
every page.
Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes- No
❑ ® Backup of sewage into facility or system'component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool -
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
p
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 . Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑:" 1:1 the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section IE the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department. `
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for Cotuit MA 02635 .5/1/18
every page.
Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ElWere as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break outZ,
® ❑ Were ail 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?
® a Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection Yes No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
_Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: No recent pumping
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and,
maintenance contract(to be obtained from system owner)and a copy of latest.
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
® Other(describe):
No D-box -
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Septic tank and Pit B per age of the home, leach pit C new in 1992 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
>10'
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
18"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
10"
Sludge depth:
t5ins.doc•rev:6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
uTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
everyage.ed r Cotuit MA 02635 5/1/18
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle >12
11
3„
Scum thickness
Distance from top of scum to top of outlet tee or baffle >2"
Distance from bottom of scum to bottom of outlet tee or baffle >211
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3 years to prolong the life of the system, pumping suggested at this time
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: '
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
- gallons >
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.);
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
Cityrrown State Zip Code bate of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No indication of a D-box
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box,etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pit B is full at this time, it is the original pit, pit C is damp, sidewalls are clean, it is 3' below grade,
cover raised to 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
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M SVB,r 134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
6
3� (4
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for Cotuit MA 02635 5/1/18
every page.
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
>12'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high groundwater elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping
You must describe how you established the high ground water elevation:
The site is at 53'msl and nearby surface water is at 12'msl
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 134 Oxford Dr.
Property Address
Milles
Owner information Owner's Name
is required for every page. Cotuit MA 02635 5/1/18
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to M Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
l
i C)
MAP O2`
ECOJECH PARCEL
Environmental LOT
www.eco-tech.us �
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000)
TITLE 5
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A �--
CERTIFICATION _ MECE ED
Property Address: 134 Oxford Drive
Cotuit A R R 13 2004
Owner's Name: James and Gloria Case
Owner's Address: 134 Oxford Drive TOWN OF BARNSTABLE
Cotuit ,MA 02635 HEALTH DEPT.
Date of Inspection: April 8,2004
Name of Inspector: (Please Print) David D. Coughanowr,R.S.
Company Name: Eco-Tech Environmental
Mailing Address: 43 Triangle Circle
Sandwich,MA 02563
Telephone Number: (508)364-0894
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
g 1
Inspector's Signature �- L��/ �- �S Date: Apt;
� (6, &o+
P
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority
NOTES AND COMMENTS
Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Case
Date of Inspection: April 8,2004
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
A] System Passes:
Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR
5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no,or not determined(Y,N,or ND). in the_for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not),is structurally
unsound,exhibits substantial infiltration or exfiltration, or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout or high static water level 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 Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced.
ND explain
The system required pumping more than 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
ND explain
2
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Case
Date of Inspection: April 8,2004
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety and environment.
1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) System will fail unless the Board of Health(and public water supplier,if any) 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 I 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 by a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form
3) OTHER
3
Page 4 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Case
Date of Inspection: April 8,2004
D)System Failure Criteria applicable to all systems:
You must indicate either"yes" or"no"to each of the following for all inspections:
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 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
X Any portion of the SAS,cesspool or privy is below high groundwater elevation.
X Any portion of 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 1 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.(This system passes if the well water analysis,
performed by a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form)
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore, the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E)Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply •
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of apublic water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in section D above the large system has failed.The owner or operator of any large system considered a
significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Casey
Date of Inspection: April 8,2004
Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following:
Yes No
Y _ Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the last two weeks?
N Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of this inspection?
Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A)
Y _ Was the facility or dwelling inspected for signs of sewage back-up?
Y _ Was the site inspected for signs of breakout?
Y _ Were all system components,excluding the SAS. located on site?
Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for
the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum.?
Y _ Was the facility owner(and occupants, if different from owner)provided with information on the proper
maintenance of subsurface disposal systems?
For information on the proper maintenance of subsurface disposal systems please go to:
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Y _ Existing information.For example,Plan at the Board of Health.
Y _ Determined in the field(if any of the failure criteria related to part C is at issue,approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Casey
Date of Inspection: April 8,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept.
Number of current residents 0
Does the residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no):no :(If yes,separate inspection required)
Laundry system inspected (yes or no): n/a
Seasonal use(yes or no): no
Water meter readings,if available(last two year's usage(gpd): 188 gpd
Sump Pump(yes or no): no
Last date of occupancy: April,2003
COMMERCI4,L/INDUSTRL4 L:
Type of establishment:
Design flow(based on 310 CMR 15.203):: gpd
Basis of design flow(seats/persons/sgft/etc.):
Grease trap present: (yes or no)
Industrial waste holding tank present: (yes or no):
Non-sanitary waste discharged to the Title 5 system: (yes or no).
Water meter readings,if available:
Last date of occupancy/use:_
OTHER: (Describe):
GENERAL INFORMATION
PUMPING RECORDS
Source of information: System not pumped in recent past(Owner)
Was system pumped as part of the inspection: (yes or no) No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM:
X Septic tank,dist6butien box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternate technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Age: 29+years Certificate of Compliance issued 11/26/75(BOH permit#342)
Were sewage odors detected when arriving at the site: (yes or no) no
6
Page 7 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Case_
Date of Inspection: April 8,2004
BUILDING SEWER_(Locate on site plan)
Depth below grade: 2 ft
Material of construction:_cast iron X 40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting,evidence of leakage,etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling_
SEPTIC TANK:Yes (locate on site plan)
Depth below grade: 12 inches
Material of construction: X concrete_metal_fiberglass—polyethylene
_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of
certificate) -
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth: 8 in
Distance from top of sludge to bottom of outlet tee or baffle: 26 m*
Scum thickness: 6 in
Distance from top of scum to top of outlet tee or baffle: 8 in
Distance from bottom of scum to bottom of outlet tee or baffle: 10 in
How dimensions were determined: Probe to top of tank
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pumping recommended at this time and maintenance pumping is recommended eve!y 2 years. Liquid level at
outlet invert.Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out.
GREASE TRAP: none (locate on site plan)
Depth below grade:
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:
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
I
i
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Case
Date of Inspection: April 8,2004
TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal _fiberglass_polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow:_gallons/day
Alarm present(yes or no):_
Alarm level:_ Alarm in working order(yes or no):_
Date of last pumping:
Comments:(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: none (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.)
PUMP CHAMBER: none (locate on site plan)
Pumps in working order: (yes or no)
Alarms in working order: (yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Casey
Date of Inspection: April 8,2004 r
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required)
If SAS not located,explain why: _
Type:
X leaching pits,number 2
_leaching chambers,number .
_leaching galleries,number 4 =
_leaching trenches,number,length
_leaching fields,number,dimensions
_overflow cesspool,number
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure,level'of ponding,damp soil,condition of vegetation,etc.) .
Soils above leaching pits appeared unsaturated.No evidence of surface ponding,breakout,lush vegetation,or
other evidence of hydraulic failure was observed.
CESSPOOLS: none (cesspool must be pumped at time of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,,
etc.):
PRIVY:none (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Casey
Date of Inspection: April 8,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100'(Locate where public water supply enters the building)
LEACH
O PIT LOCATIONS
LEP TH A B
I 20 ft 7.5 ft
2 22.5 ft 13.5 ft
2 3 34 ft 34 ft
SEPTIC TANK 0 4 43.5 f t 49.5 f t
FL
B
EXISTING "
DWELLING
# 143
W -
Z
J
W
6I
3
OXFORD DRIVE NOT TO SCALE
10
i
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Oxford Drive
Cotuit
Owner: James and Gloria Casey
Date of Inspection: April 8,2004
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to ground water: 45+ feet
Please indicate(check)all methods used to determine high ground water elevation:
Obtained from system design plans on record-If checked. date of design plan reviewed 11/8/94
Observed Site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of health-explain:
Checked local excavators,installers-attach documentation)
X Accessed USGS database
You must describe how you established the high ground water elevation.
Barnstable GIS department records indicate that property is over 45 feet above groundwater table.
11 � i
TOWN OF BARNSTABLE
LOt: TION 13�t 069Wn , SEWAGE # a—
VILLAGE_ccmcx ASSESSOR'S MAP & LOT Cl Le 671
INSTALLER'S NAME & PHONE NO. V,19YOrE— c.E.W -, _
SEPTIC TANK CAPACITY `000
LEACHING FACILITY:(type), ZQ22 L6V lbur (size) 6Xg e
NO. OF BEDROOMS- PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER �MM (,�q �
DATE PERMIT ISSUED: 17--1A--)—
DATE COMPLIANCE ISSUED: 77- -42,
VARIANCE GRANTED: Yes No f�
��
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ti
' 4
4'; r
�.
'b-r �
No..9. Fim............... ....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
ApplirFation for Bispos al Works Tonutrn.r ion Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................__:............................................................................. _..---------.........._.................---------•------------------••-----------.....--•-------•-
Location-Address or Lot No. _
.......... '! C _ -----•----• ----•----•............. .........C �?c....-_C (...
. Owner Address .....................
.-- •-• y
Installer Address
� Type of Building Size Lot...........................S q. feet
U Dwelling No. of Bedrooms..........-3.......... .Ex Expansion Attic a g— ----------------- p ( ) Garbage Grinder ( )
aOther—Type of Building ....K ............. No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----•---------------------------------------------------•-•••-••-•--•---•••••--•-••----•--•--••-••••••--•---•••---•--••-••-...•---•........-•-••-•-
W Design Flow...;----------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity.CCW...gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fZ4 Test Pit No. 2................minutes per inch Depth of.Test Pit---................. Depth to ground water........................
•---------- •-----------•---•----------•------------------------•----•--•--------•.--------•-----
O Description of Soil...... ..._ ?..... , �. ......._
x
w
x ------------------------------------------------------------------------------------ .................................
U Nature of Repairs or Alterations—Answer when applicable_...__ �1 -......................................................
1�-•----------- 1�1`Ij �c'�� tC(�l' -----.r- .___.- ....3� r--------------------•-------------------------------------------•---•-•----•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code— nd further agrees not to place the
system in operation until a Certificate of Complianc s b n 'ss by t of health.
Signed -------- --- --------------- --- . ..........---- ---------------- ---------------- ---- --------------.........-................
Da
Application Approved B -... --..'
- Date----- '-------'
Application Disapproved for the following reasons- ----- -- - ------------------ -------------------- --------- -------------------------- ---------------- -- -----------
-------------- ..-------------.....------ ----...................
Date
Permit No. .........:- -.- ........ ... .. Issued ----- .��. � -------------
Date
Finc
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tonstrnrfion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (v) an Individual Sewage Disposal
System at:
................_................................................................................ ...............---............_...................................................................
Location-Address or Lot No.
.... ..........13�-•-c�C _6�/l, CcG7r�T
Owner
......._Address...........................................
a -----•...• �r�C� �r. T:. 1 /�!!1!=�c,�',cJR..:. SAKX� ff-, T{Cv1 ill,
Installer Address
d feet Type of Building Size Lot___________________________S q.
U Dwelling—No. of Bedrooms..........3________________ _____Expansion Attic ( ) Garbage Grinder ( )
aa Other—T e of Building /Z�_____________ No. of ersons._.______.__.______..__._.__ Showers
YP g ----•--•-----= P ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid*capacity_/0�0_gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_ ............._...... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date....._..................................
1--7
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 i •---•-••-------e r--••-•••--•-•••---••••---------•--_....•.........................•---••---------•---•-•---•...-----....._..----._..._.........._.
x
Description of Soil_....___QCA�_-_3..'.�__... !`dF.... ��_________
V .........--•-•-•--------•-••----••-••-•-•------•••-•.....-•••---•-•••-••••------------••••••••••-••-•••--------------•-••-••••---•---------•._._..
W �}
VNature of Re airs or Alterations—Answer when applicable.------� �_C(l.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmenl Code,ZE riders' f further agrees not to place the
system in operation until a Certificate of CompliaA'seen is//sue'dby th�b ax of health.
Signed.--------- ;_--- --- ------- ---------- ------. ---------------
A lication A roved B '" �Y ._ I� J.e ---- --------- ------------------ ------------- may s�
PP PI? Y - d---...
Dare
Application Disapproved for the following reasons:
-----------------......
�9
............................................----------------- --------icy--/-----...-----------------...----------------------------------- ----
----------------------------------� ---------------./ Dare
Permit No. �' .7---------- ................ Issued .."°-- -----� .....----------
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(fe>r#tfirate of Qlampltttne
TI1 TO CERTIF That the Individual Sewage Disposal System constructed ( ) or Repaired ( l%)
�,
Installer
has been installed in accordance with the provisions of TITLI�5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .eCONSTRUEID(AS
_ .:- '�` -....-��.... Gated
pP l? ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. `IN
DATE------------------ --- ........................ �---------------------------------------- Inspector ............cam. .....-'--- ----- ----------------------------------------
a -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No......................... FEE.....
.....e"
Disposal Worko To�,tgtr ion rrmi#
Permission is hereby granted J• �� ... 1 2.............................................................................
to Construct ( ) or Repair (V) art_ Individ alSewage Disposal System
at No...- �..f. 1 'T - _ `` t? --------
---- -------------------•-
Street ,
as shown on the application for Disposal Works Construction Permit No�� n' __---- ed_____ �'_._T'W fi..���
........................ ....... �
Board of Health
DATE..........----- •-••-�-•-rt--�---�----------------------------------
FORM 36508 H0813S&WARREN.INC.,PUBLISHERS
r'
No........ Fs$....,1 ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
_..1`16t t��..... OF............ .,.:. ...�
Appliration -for Biipoiittl Works Tomitrurtion Vrrui t
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-a� O-,r.!cmb---D_R......oxvt.._ - ----------------------------------------------------------•...-----------------------------------
_ cation-Add or Lot No.
s /I!J S•.......... 5
••-----•---•-•----------------------•••------------
Owner Address
-'•------'-'-•----"------ -----............................
...-------............----------- ._..._..-•---_.•---�:•-.----
Installer Address,
UType of Buildin Size Lot....44fo-+�_o- ------- feet
Dwelling—No. of Bedrooms---------- --__-Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons........f1�_-_._._-___.-_- Showers (/) — Cafeteria ( )
Otherfixtures --•--------------------------------•-----.......------.................................
Design Flow...................,................. perpersonperdaily gallons.P P P Y• Y m•�
WSeptic Tank—Liquid capacitv/L ►.gallons Length................ Width................ Diameter........-------- Depth................
x Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No........./-------- Diameter..,l�__._... Depth below inlet.................... Total leaching area.---.-..--._-_____sq. ft.
Z Other-Distribution box ( ) Dosing tan ( ) 0, �' jj - 7Is"'
Percolation Test Results Performed b _.... _.. --.._- Date---- �J`___._....
W Y---' -- :li�Ys• - - -
Test Pit No. 1_______________minutes per inch Depth o "Pest Pit_..___........_..___ Depth to ground water....__._--_-._.._...-...
LT. Test Pit No. 2................minutes per inch Depth of Test Pit.--___-___-.._____-- Depth to ground water--.-..---__-----.------.
W
...Soil-� ' f0 Tr' -
x Description of z i / V_Aji" / --la
CF..��
V --------------------------------- - - nn_ 6 .......
..
U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------.----_------.---.....
---------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------•-------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal-System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.......--- •.
i'
Date
Application Approved BY E Z }---------- " .:-.?.J7 ..-
/ Date
Application Disapproved for the following reasons:-----•-••---------------------•-•--- ----------•-----.......--------------.._..---._....._....---•............•.
----•--•-•-••----------•----•--••----•-----------------------------------•----•-----•----------•-•---------•---••-----------•----------•-----------•---•-----------•--------------••--------------.-----
Date
PermitNo......................................................... Issued........................................................
Date
7S �
s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. ... ...._..........OF................................................................................I........
Appliration -fur M,ipoottl Works Tonmrurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
---
_ ocation,Addre s. or.
Lot No.
.............•.... .................................._............
W Owner Address
'r a - ............. -------------------------'----
Installer Address
UType of Buildin Size Lot..�0- �,_o�_-_-____Sq. feet
Dwelling—No. of Bedrooms.......... ..............................Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ____________________________ No. of persons..._....ee�__--______-___-_ Showers (/ ) — Cafeteria ( )
Q' Other fixtures
W Design Flow___________________ Q.................. per person per day. Total daily flow..............._s?4to ..
W Septic Tank—Liquid capacity/A��)_.gallons Length................ Width................ Diameter__---_ ---.__-_ Depth----------------
x Disposal Trench—No--------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------�--------- Diameter__/°�,5..__..__ Depth below inlet.................... Total leaching area-._-_-..-.----__-_sq. ft.
z Other Distribution box ( ) Dosing to
W
Percolation Test Results Performed by._.. ... _ ----- ---------:----_.._---_-- Date-_Ci-_/a__'?J'`___---_..
Test Pit No. I................minutes per inch Depth "hest Pit-------------------- Depth to ground water..--_-._-_------.--_-
rXq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--_---._--.--_--.-.
E 6 : •-•--- --- ri �� C
Description of Soil r l -------------�------------- � (!� f
U -------------------------- � ' �.r�'`'-------------_--__----------•-•---•---------•-•- --••-
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--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.---............................................................................................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Y.
Si ed------ j' ---- -----------------------------
--------------------------------
� Date _
Application Approved By............. .. . .------ --� .`-E•,�/!.G' 7 ------
Date
Application Disapproved for th.e following reasons: ...............................................................•-------.._...
----•-•----------------••---------•-------•-•------•------•--•-•-----------•---•------•-•-----------.---..
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O �AI_T H1......... ....OF.... . �:...(1..
"Trrtif irat>i of 'Q1,11mplimnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ----------------- -------- 1 -------
1
at.-o �� I!-� --------------•-----•-----------.......................................................
has been installed in ccor ance with the provisions of XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit NCO..I'nI ............. ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTOR3.� , 7b -
DATE - // ............... Inspector----L----...-t-....-...---------------•-------------•-----------------------•-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTIJ
...............OF.... . .� . .2 -r/y
No3L .-----••-- FEE.
. ...............
%spinial Markii Tontitrurtion run it
Permissioni hereby granted----------------------------------------------------------------------------------------------------------------------------------------------
to Conslct
or Repa' ( awn ti dual Sewag System
at
Street
as shown on the application for Disposal Works Construction P it !. _.._.!. Dated..,�_J.�.�. - 7
- - ----------------------------------
oard of Healt
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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5EW.QC,E _PERMIT UO.
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_DPkTE_ PERMIT
- DATE COMPLI /ONCE - ISSUED :
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