HomeMy WebLinkAbout0175 OXFORD DRIVE - Health 175 OXFORD DRIVE, COTUIT
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i
t
Town of Barnstable
" Inspectional Services Department
i BARN ASS'1�
61A8S. ' Public Health Division
9
'°rfc ram" 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4987 8166
March 22, 2021
SOMMER, MONICA M TR
175 OXFORD DRIVE
COTUIT, MA 02635
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 175 Oxford Drive, Cotuit, MA was inspected on
03/10/2021 by Michael Sears, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• The distribution box is rotted and needs to be replaced.
You are ordered to repair or replace the distribution box within one (1)year from the
date you receive this notification..
Failure to repair/replace the distribution box within the deadline period will result in
future enforcement action.
PER ORD R OF HE BOARD OF HEALTH .
T o as I Ke n S. CFI0
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\175 Oxford Drive Cotuit.doc
i
rnstable Town of Ba
"^ ' Inspectional Services Department
prFD MP'f s
Public Health Division
200 Main Street, Hyannis MA 02601
Oft-ice: 508-862-4644
FAX: 508-790-6304 Thomas A. McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
i
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE(1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool
❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation
❑ A portion of the cesspool is located within a Zone 1 to a public well
❑ A portion of the cesspool is located within 50 feet of a private water supply well
with no acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
VIER
I _b,
0
Repair deadline: Igor
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
_..: Commonwealth of Massachusetts
oar -e3�-
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
175 Oxford Dr.
V�
Property Address
Monica Sommer
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 3-'10-21
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites Path
Ir--� Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
`````�������N OF
2. ® Conditionally Passes ,;�,`�•'
MICHAEL 'yam
3. ❑ Needs Further Evaluation by the Local Approving Authority =0. SEARS
*: No.SI14430
a 4. ❑ Fails . C1
RTIF�.
''��••��i5 I N SP`��'````���
3-10-21
Inspector's Sig na Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to '
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform'
in the future under the same or different conditions of use.
t5insp.doc•rev.M6/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c~ , Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
175 Oxford Dr.
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes: w
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial,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)-
D Box walls are gone and needs to be-replaced
t5insp.doc-rev.7/26/2018 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
c Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.......... !% 175 Oxford Dr.
Property Address
Monica Sommer
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 3-10-21
page. Cityrrown State Zip Code Date of Inspection .
C. Inspection Summary (cont.) .
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
t _
❑ 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 ElN ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
175 Oxford Dr.
u�
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh'
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
s
You must•indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters .
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
........... .�!% 175 Oxford Dr.
u� -
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well. I
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
El El Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
175 Oxford Dr.
Property Address
Monica Sommer
Owner Owner's Name
information is Cotuit Ma. 02635 3-10-21
required for every
page. City/Town State Zip Code' Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
I
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ 'Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c Commonwealth of Massachusetts
�n Title 5 official Inspection Form ,
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments: _
175 Oxford Dr.
u� Property Address -
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma'. - 02635 3-10-21
page. City/Town State Zip Code Date of Inspection
D. System Information `
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description: T
a
Number of current residents: ' ..
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a.water treatment unit? t ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.) „
Laundry system inspected? r 4 = ❑ Yes ® No
a
Seasonal use?, - ❑ Yes ® . No
x q 2019-110000gal ,
Water meter readings, if*available (last 2 years usage(gpd)): 2020-161000ga1
Detail;
-
Sump pump? i t r ❑ Yes ® No
Last date of occupancy: Present
bate
t5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
175 Oxford Dr.
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
• f
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below): `
y -
3. Pumping Records:
Source of information: 2017
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: - gallons
How was quantity pumped determined? -
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' <iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 175 Oxford Dr.
v-
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be'obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
5-4-84 #83-1038
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 42„feet
Material of construction:
❑ cast iron (140 PVC ❑ other(explain):
Distance from private water supply well or suction line:. feet
Comments (on condition of joints, venting, evidence of leakage,:etc.):;:
l5insp.doc.-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official I,nspecti'on Form ',
ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
175 Oxford Dr.
U Property Address .,.
Monica Sommer .
Owner Owner's Name `
information is required for every Cotuit '" Ma. 02635 3-10-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site"plan):'.
Depth below grade:
feet
Material of construction:
® concrete ❑ metal' ❑ fiberglass' ❑ polyethylene ❑other(explain)
1000 gal
If tank is metal; list age: years°
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -
`- 1000 gal
Dimensions:
Sludge depth:
- 2911
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 0-
8-1
Distance from top of scum to,top of outlet tee or baffle. -
Distance from bottom of:scum to bottom of outlet tee or baffle
How were dimension`s determined? Sludge judge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, -
liquid levels,as related to outlet invert, evidence of leakage, etc.):
1000 gal tank with in baffle and out baffle in place, both covers at 32".below grade
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of.18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
II Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
175 Oxford Dr.
u
Property Address
Monica Sommer
Owner Owner's Name
information is Cotuit Ma. 02635 3-10-21
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
F
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
175 Oxford Dr.
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16x21 with 1 outlet pipe, cover at 25" below grade
D Box walls are gone and needs to be replaced
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
F^
I `
Commonwealth of Massachusetts
Title 5 official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
........... ,. 175 Oxford Dr.
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
f
If SAS not located, explain why: `
Type:
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
EJ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
tl, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 175 Oxford Dr.
u—
Property Address
Monica Sommer
Owner Owner's Name
information is Cotuit Ma. 02635 3-10-21
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is a 1000 gal pit, pit is dry and clean with no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow F ❑T Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
`I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.,, 175 Oxford Dr.
u-
Property Address
Monica Sommer
Owner Owner's Name
information is Cotuit Ma. 02635 3-10-21
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privylocate on site plan):
( p )
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
y
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts ;
�n Title 5 official Inspection Form
; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
175 Oxford Dr.
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including.ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
d
&A
10
55 a O
3- 36
OF/Wqy c,��G
MICHAEL %N
=o: SEARS 24
*: No.SI14430
FRT
5 INS?
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
175 Oxford Dr.
V
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
1-6-81
If checked, date of design plan reviewed: Date
Date
❑ Observed site (abutting property/observation hole within 150.feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
No ground water per plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
f
} Commonwealth of Massachusetts`
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 175 Oxford Dr.
u,
Property Address
Monica Sommer
Owner Owner's Name
information is required for every Cotuit Ma. 02635 3-10-21
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Grn�t '
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
No. � �0" Fee 7 T
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:—�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for -Mispo4al 6pstrin (Construction VErmit
Application for a Permit to Construct( ) Repair O( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
P
Location Address or Lot No. 11S exFe0Z DR. Co%�4i'r Owner's Name,Address,and Tel.No. t
Assessor's Map/Parcel O z 110 31 MZ h iLA S0"rA e R ,
F'•.
Installer's Najne,Address,and Tel.No. Ramr 13 cvR Co . Designer's Name,Address,and Tel.No.
363 wk•k 5 PAt 1+ S. \/4,vuoorli 6Z.6-4
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
�,nS�Ak1t �.IE� b63 l (o 3vu lA)• 1 Ascr %,eAne
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 Certificate of
Compliance has been issued by this Board f He
Signed Date 3' 1 7 Z 1
Application Approved by Date- 2,1
Application Disapproved by Date
for the following reasons
Permit No. 2�nj (, Date Issued 3
_,,gwX.sX••....,i;L:;:.+h;,,.,•a_n�c1,y..:;i•.-;.::t4..a m�";�.,��i.•,..:^,y., .,;�-r�,i.,..,�y"v. -5:,�,(`�'•..,. .''.',it,,,,. .-., ..'..,�d..,t, .„ ,A"...+^.
(.
No.", Fee rt
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye4�.
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Mistl08aY''�pstelTC �OnstCUttiOnQrtlYit
Application for a Permit to Construct( ) FRepair( Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components
Location Address or Lot NoJ 1 6 X F&D b ok r T Owner's Name,Address,arid Tel.No.
Assessor's Map/Parcel 0 Z l �0 3 l ML n t C A S 0"1M c R rp�°
Installer's Name,Address,and Tel.No. RGbk�f $evR Co • Designer's Name,Address,and Tel.No:
arm 3 wl. tcs �A TlF 5. yM�vuo�ttl o ztobN
so>✓ - �t�� - �a �-1
41
Type of Building:
Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder( )
Other, Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures f R
Design Flow(min.required) A gpd Design flow provided gpd
Plan Date Number of sheets Revision Date'
Title
Size,of Septic,Tank Type of S.A.S.
Description of Soil f'
Nature of Repairs or Alterations(Answer when applicable)
A(C RD . lei. 1 Aicr 6 k/ctj
,w f
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 Certificate of
Compliance has been issued by this Board .f Health.
Signed � Dater 7 Z
.A C _
Application Approved`by Date
Application Disapproved by Date a'
for the following reasons'
Permit No. � j;1 "'� r Date Issued 3/) _e -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( �,)'� Upgraded( )
a
Abandoned.(. )by!_:-.-. ✓ F��,?
' at o Myg ty 66 has been constructed in accordance .
with the provisions of Title 5 and the for Disposal System Construction Permit No. f' dated 3/Z,if 2/
Installer (//A^ei Designer
#bedrooms /v J A" Approved design flow �(�}� gpd
The issuance of this permit shall not be co•�ssttrrued as a guarantee that the system'wilkfunct designed. _
Date rat ( Inspector �1_
-F - No. ? { '�?s Fee -7f r
THE COMMONWEALTH OF MASSACHUSETTS
p ,` PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
i
Disposal �&pstem Construction Vermit
Permission is hereby granted to Construct( / �`"
) �y ,Repair( j,.)�' Upgrade( ) Abandon( )
System located at � A/�^{ FT+ (w
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within,three years of the date of this permit.
Date ?j27i J T( Approved.by // ^�""".�•
. t .
:BORTOLOTTI CONSTRUCTION, INC.
45 INDUSTRY ROAD,.MARSTONS MILLS, MA 02648:
5081"771=9399 508-42878926 TAX: .508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
n • �
Property Address:: / a
Date Of Inspection Inspector's.Name: '
O ner's Name and Address: 44
CERTIFICATION STATEMENT:
I Certify that I have personally Inspected the Sewage Disposal System at this.address and that the informa-
tion reported below is true,accurate and complete as.of the time of Inspection.. The Inspection was perform-
ed based on my Training and Experience in.the Proper.Functiomand Maintenance of On-Site Sewage Dis
posal Systems.TIV system
Passes
Conditionally..P sses
Needs Furt . r. valuaf n he Local Approving Authority.
Failure -
Inspector's Signature Date: . �f.�Q
The System Inspectors 1 ubmrt a c py of this Inspection Report to the Approving Authority with 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.. .
INSPECTION
A) SYSTE PASSES:
I have not.found any Information.which indicates that the System violates any of file fail-
ure criteria as defined in 310 CMR 15.303. Any Failure Criteria:not,eyaluated are indi-
cated below
B) SYSTEM CONDITIONALLY PASSES:
One or.more.System Components need to be Replaced or Repaired. The.System,.upon
completion.of the Replacement or Repair,-Passes Inspection.
Indicate yes,nor,or not determined(Y,N,OR ND)..Describe bases of determination in.allinstances. If"not
determined",explain why not.
The.Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfl.-
tra.tion,or Tank.,Failure is imminent. The System will Pass Inspection if Existing Septic Tank
is Replaced with a.;conforming Septic Tank.as Approved by the Board Of Health.
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 Inspectionaf(With Approval of the Board Of Health):
}
SUBSURFACE..SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A ;
CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is leveled.or replaced
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.:
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board Of Health in order to determine if :
the System is failing,to protect the Public Health,Safety and the'Environment.
1.)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN XMANNER.WHICH WILL.PROTECT THE
PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS.FUNCTION-
ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a Septic Tank and Soil Absorption Systenr.and is within 100 Feet to a.Surface
Water Supply or Tributary to a Surface Water Supply. .
The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public
Water Supply:Well...
The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private
Water Supply Well.
The System has a Septic Tank and Soil Absorption.System and 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 from pollution from
the.facility,and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less .
than 5 ppm.
D)SYSTEM.FAILS:.
I have determined that the System violates one..or more of the following Failure Criteria as defined
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.
Backup of sewage into facility or system component due to an overload,or clogged SAS
or cesspool.
Discharge or poll di 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.clog-
ged.SAS or,cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day:flow
Required pumping more than 4 times,in the last year,NOT due to clogged or obstructed
pipe(s). Number of times pumped
- 2 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM
PART A
CERTIFICATION(continued)
Any portion:of the Soil Absorption System,cesspool or privy is below.the high groundwater
elevation..
Any portion:of a cesspool or privy is within 100 Feetof a surface water supply or.tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone l of a Public Well.
Any portion.of a cesspool or privy:is within 50 Feet of a private;water supply well.
Any portion of a.cesspoolor privy isless 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
compounds,ammonia nitrogen and,.nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following.criteria apply to a large system in addition to the,criteria.above;;..
The.design flow of a.system is 10,000 ggd.or greater(Large System)and the system:is a significant. ..
threat to public health and safety and.the environment because one or more.of tl�e following.
conditions exist:
The system is within 4W 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 are.a.Interim Wellhead Protection Area
(IWPA)or a mapped Zone Hof a public water supply well.
The owner or operator of any such system shall bring the system and facility into;full compliance with the
groundwater treatment program requirements of 315 CMR 5.00 and 6.00: Please.consult the local
regional office of.the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if.the following have been done:
Pumping information was.requested of the owner,occupant;and Board of Health.
None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that:period'..1 Large volumes of water have not,been
introduced into the system_recently or as part,of this inspection..
/ As-built plans-have been obtained and examined. Note if they are not available with N/A.
_ /The facility.or dwelling was inspected for signs of sewage back-up.
The system does not receive.non=sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
✓All system components,excluding,the Soil Absorption System,have been located on site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was in
spected for condition of baffles or.tees,material of.construction.,dimensions;depth of liquid,:
depth of sludge,depth of scum.
The size and loca.tion of the Soil Absorption System on.the site has been determined based on
existing information or approximated by non-intrusive methods.,
- 3 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART.B
CHECKLIST(continued)
t/ The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS.
RESIDENTIAL:
Design Flow:g_110)_gallons Number of Bedrooms: N tuber of Current Residents:
Garbage Grinder: ;:. Laundry Connected To System: Seasonal Use:
Water Meter Readings,if available:
Last Date of Occupanc} L& Cz_'4 ( fYA_'
f'OMMERCIAL/INDUSTRIAL:/X& •'
Type of Establishment:
Design Flow: gallons/day Grease Trap.Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: (Describe)
Last Date of Occupancy:
GENERAL. INFORMATION
PUMPING RECORDS any source of information: `
System.Pumped as part of inspection: I•yes,v me pumped: V gallons
Reason.for Pumping:
TYPE OF SYSTEM:
Septic Tank/.Distribution Box/Soil,Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any)
Other(explain):
APPROXIMATE AGE of all components,date installed(if known) and source of information:
Sewage od rs detected when.arriving at the site:
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION. (continued)
SEPTIC TANK:
Depth below grade:_ Material of Construction: concrete metal FRP Other
(explain)Dimensions: ' Sludge Depth: Scum Thickness
Distance from top.of sludge to bottom of outlet tee or--baffle: 6
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,conditioin of inlet:and outlet tees or baffles,depth Of liquid leveli
in relation to outle 'nvert,structural integrity,evidenc. of leakage,etc. A
>i..
GREASE TRAP:
Depth Below Grade: Material of Construction; concrete. metal FRP i Other
(explain):
Dimensions: Scum Thickness:
Distance from top of scum to top 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 integrity,evidence of leakage,etc.) -
TIGHT OR HOLDING TANK;_Z�2 �
Depth Below Grade: Material of.Construction; concrete metal FRP Other
(explain):
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments:(condition.of inlet tee,condition of.alarm and float switches,etc.)
DISTRIBUTION BOX: �l.
Depth of liquid level above outlet invert: .,(Nn
Comments: (note if level and distribution is a al,qvidencCof solids carryover,evidence ol leakagee into.or
s _
O t Of box,etc.)
PUMP CHAMBER-
Pump.is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc)
_ 5
_
SUBSURFACE.SEWAGE DISPOSAL .SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plap,.if possible;.excavation not required,:but,may be approximately by non-intrusive_
methods) If not blermined to be present,explain:
Type:
Leaching pits,number:. Leaching chambers,number: Leaching galleries,number:
Leacahing trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number;
Comments: (note conidtion of soil,signs,of hydraulic failure el of pondin condition of veget ion,etc.)_
f. f
i
CESSPOOLS:
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(cesspool must be pumped as part of inspection)
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation;
etc.)
- 6 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
.PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include.ties to atleast two permanent references,landmarks or benchmarks.
Locate all wells within 100 Feet.
r �
j
5
DEPTH TO GROUNDWATER:
Depth to groundwater: ` 7j. Feet. C
Method.of Determination or Approximatio
- 7 -
ra
` TOWN OF BARNSTABLE
LGCXTION r SEWAGE #
VILLAGE ASSES 'S MAP & LOT
pax,p s : NAME & PHONE NO. SO • F
SEPTIC TANK CAPACITY `/-
LEACHING FACILITY: (type) �,[ (size) ® X
NO. OF BEDROOMS
BUILDER OR WNE f�
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
Avw
� /'fo
,dI TOWN OF BARNSTABLE
LOn`A 1 ION _ SEWAGE #
VILLAGEV ASSESSOR'S MAP & LOT 022
)Q S. NAME&PHONE NO. DY!'.( f�-l�.c i � 'V�-,f� •
SEPTIC TANK CAPACITY
LEACFIING FACILITY: (type) �D4 /, (size) (a �X
NO.OF BEDROOMS &
BUILDER OR �e
PERMTTDATE: --� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
9
r
2z
VO `CAT0O SEWAGE PERMIT NO.
VLLLACE
INSTA LLER'S NAME i ADDRESS
® vS /,-e Se r.
U D OR OWNER
DATE PER IT ISSUED
DAT E • COMPLIA'NCE ISSUED 5� ��
. ��clase D
-Zi
•
N�.lt..3P103 • . Fus._. ../..-.�..:.............
•---
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........ .-•.........OF......9i p0�.�{-'-:�!A7................................
App irFativaa for Uiupu,i ai Works Towitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Loca ion-Address r Lot No.
9
W _-_ 1.> ...h. s _-_--•--•-•--•-•------------•----• --•-•- �_� ��.. ....._.. .................................
p Owner-
,-a Address
fh1 ' .... ►..�r� a.. `? �............................
Installer/i� Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.............�________:_._______ _Expansion Attic (hO) Garbage Grinder (ho)
-�
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
aOther fixtures ...................................................... 2
W Design Flow____________________________________________gallons per person per day. Total daily flow.......
.l_'&0...........................gallons.
WSeptic Tank—Liquid capacity.OG _gallons Length................ Width................ Diameter---------------. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.....1.U'......... Depth below inlet...... ......... Total leaching area_..?4k____sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by--------- ----•---•-••------•--------•---••••-----•--p------•-------•----- Date........................................
as Test Pit No. 1____ _2...minutes per inch Depth of Test Pit-------j_Z....... Depth to ground water..__00i.�'_____.
Test Pit No. 2..../-2._minutes per inch Depth of Test Pit.......I�_�____. Depth to ground water----Yl011. ____.
•-------------------• •-•••-•-----...-•--------•••-••-------------------•-----._.._�....._____e___......_.....-"•--•---_______________..........____.
Description of Soil-----Ce_.�-f_slti.. ...��Yl!�_..t...&_.....---•�--�2--------�___�_��`81.��-.�!_?'le..--��-�=-- ---------------------•-•------------.
--------------•-------- �.12= -"'.._.�.2.' �A!�ittWt ------------•-----------------------...--•-•----•--•--------------
W -------------------------------•---------------.-..----------------------...------•-----------------------------•._....-----------------------•--------------------------------------....-------•--
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI'i LZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 'ssue y thrboard of health.
eApplication Approved By........... .......................•------•-----•---__.__•--••--•--------------_.. .... _�`�D. ..............
Date
Application Disapproved for the ollowin reasons:--------•-------------------------•---------------------------•-----------------•-----•-----•---••-•-•••••-----
..................................................... - --•----- .. •-•-- - ---• Date
PermitNo......................................................... Issued.......................................................
Date
Noj_4.3t103 r Fps.....10..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........OF...... . "� ,I t' #<:)'x�•
Applira#iott for Disposal Works Toatstratrtioat jhrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
C)1 4J l'.e:'.... .4 .. � t.
Location-Address or Lot No.
� i1-',t`Own �er •1 t+ > Address
W ., •, - •..'r+ .r:..,r, 1 h r f:.p•.•.' t kl�a �• 1/?,�i A
..._. _..._. _______________________________________ _ - _...- e.7�r.._. ,- �-__.__________..............._..._.
� 1 Installer •Y`• Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms......._-7 _________________________Expansion Attic !( ) Garbage Grinder„( )
pa4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p•' Other fixtures --------------- •---••-••-..••• -
W Design Flow............................................gallons per person per day. Total daily flows. _.................................gallons.
.I J�
WSeptic Tank—Liquid*capac�yam-_ ......gallons Length................ Width................ Diameter---------------- Depth................
xDisposal Trench—No.........._•.•_.••... Width.................... Total Length.................... Total leaching area............:-------sq. ft.
Seepage Pit No--------------------- Diameter—-=__..--_-------: Depth below inlet:---._............. Total leaching area.=fr..........sq. ft.
Z Other Distribution box ( ) 1 rposing tank ( ) �.
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1________________minutes per inch Depth of Test Pit__..-i_'.__....... Depth to ground water;�,.:t....._.___..._---
"
Test Pit No. 2�_�......._minutes per inch Depth of Test Pit.....w.t_.......... Depth to ground water____...............
�+ •............................................................................................................................................................
D Description of Soil..... `.. j..�'..I-,A T) . /^-" -• 7 '/�_'._:_.1\U h(—, i I`J'o;i e 1 sA it
U -- 3' + 4 c"r(r S a o +t r i t- .....................
� •--•-----•-•---------•------------------•----.....•••---•--•--.._..--•••-•....--•--•••-•---•••----•-----------------------------...-•--••••••••......-••-••-••-•-•••••-•-•-•-...........•••...._.._•-•••-
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue'by the board of health.
t•
Sign; .r"�_-......---='....../......-_r'-! _,........•---...........-......----- -•f ------ .....
D
Application Approved B --••••-
r paw. a9
Application Disapproved for the ollowin reasons_____________ `" ` __ I _____ _
--- ...._.._.
x Date
PermitNo......................................................... Issued--------------=------------....._--•-••......-•-•-----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ......................... ....................... ....:..................................
Qurrtifiratr of Tootpliattrr
THIS IS TO CERTIFY, That the Individual Sewa e Dispo al,System stem coriAtructed ( ) or Repaired ( )
bye....................................r' t a l[.v 'l 2stalier
1- -----•----•--------------------------------------------
s� ,rr -:.........
-----•----•-------------------•--__---------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as es ed in the
application for Disposal Works Construction Permit Nok-In,�!!lS_,�.. ............... da.ted__..._ :"�.. c'..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL /FUNCTION SATISFACTORY.
DATE...4A -----•----•--•--------------------------•-------••---- Inspector =
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t!�A/..................OF...... 1� �x r.�
_. .................................. FEE. �e...............
Disposal Works Tonstrudiott Pgrutit �
Permission is hereby granted '...................../!..., ........rc?t1!__... .........
.,r.................
. ..C. ............
to Construct (' 1 or Repair ( ) an Individual Sewage Disposal System
at No..- --'------•-----'�`' �..A
r .... .: ............f4f r )t Streeter �'tt a„_..__.f--: r
as shown on the application for Disposal Works Construction Permit ................ Date �,' O. a_......._......
t r`
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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LEGEND
EXISTING SPOT ELEVATION Ox0 CERTIFIED PLOT PLAN
OF �
EXISTING CONTOUR ---- 0 -- ��N ASS'ti\ LOT 2 2-
FINISHED SPOT ELEVATJON v� ROBERT G;, C.O TO / 7
FINISHED CONTOUR 0 BRUCE
APPROVED $ BOARD OF HEALTH + ,,ELDRED N IN
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S-'���� SCALE � �'� �J� � .DATE ��.i s -� i zz�f3s�
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� REDGE ENGINEERING CO. Ill udi-IM
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CLIENT.�'��'M'�`�� I CERTIFY THAT THE PROPOSED
EGISTERE REGISTERED JOB NO. �f32�7 BUILDING SHOWN ON THIS PLAN
CIVIL LAND DR.BY, � �� CONFORMS TO THE ZONING LAWS .
ENGINEER RVEY R --- OF BARNSTABLE , PASS
712 MAIN STREET . CH. BY, - ;Di/E.
NYANNIS MASS. �--' SHEETL OF REG. LAND SURVEYOR
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