HomeMy WebLinkAbout0275 OXFORD DRIVE - Health L275�Ojcford Drive
P1 034
I
No. 4210 1/3
ESSE TE
10%
l
0
i
i
I
i
i
y
Y
1
I
1
I
Y,
j
TOWN OF EA tNSTABL.E
LOCITION: o�
p,,SSF5SmTt'S
IN9T 3.t.EW IS MAIM&]MCTIdE NO
sic TAIqK CACrrx /.
LEACkilft`iG I��CIt;1TY (�s+pe)
Uc70
� NO �t�'�laDktOC�MS -�
tag Ova
t k 1V�ITAA'I'E. �...- ,.. CC�WU.�S+it DAT�:.,_w.:��w.- .�.-
Sepmi awon}ytsetunca Betv�eeta tt7e'
Maxicnuml d}usteO Graurttiwatet'l'litsta tl cBcttom nfl.a�Ghin�t�f�r,I ity
Fee+
hate IaB r Supply�1Y491, lie Gt* pAc�taty x►y..v�tst9s cxtst
ate site ac.'wlt�int10 fee aF tenetut�g ftgcbty) ec�9:
Ecli}cyf /e��and aid Leacli<utt 1~mo�i¢y{s ` i�y wettAndS ex4sc Tee
tvit�it13Q0 feet of teaching fucltaty} r
O
-C
w
o
oA
r 1
WN OF BARNSTABLE
LOCH' ION 1t (� .Y SEWAGE #
YILLAGE l%( k11�V� ASSESSOR'S MAP & LOTc�'�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) l (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by � �.f.
Vito
0 6-s s c- 6
a
B� n T
n
t.
Fd1___
Commonwealth of Massachusetts ,
:a=1 Title 5 Official Inspection, Form
' , A Subsurface Sewage Disposal System Form -Not for,VoluntaryAssessments
e;!ar 275 Oxford Dr
Property Address
Christopher Sherman
Owner Owner's Name
information is /
required for every Cotuit V. ,;1: MA. 02635 10-28-17 -
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.
A. General Information cSl
l ata.
S
1. _ Inspector:
Shawn Mcelroyi- i.;
Name.of Inspector "
Upper Cape Septic Service + . ...
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
_ I certify that l have personal ly.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. lam a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 16.000). The system:
® Passes r ',tl..' . + . ; E1 Conditionally,Passes. , r„ r, ❑-.Fails ,
' €r Ir;.1 , .ry ,E_, , , F" „ "+ •'i i•', �- ��,.. ,t r` u f, I .. ram.:t.,:�� � ..(.
s i 0 -Needs Further Evalu by the Local Approving,Authority
10-28-17
Inspector's Signature ``` " ' Date
The system inspector shall submit a"co•py 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.6/16. - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
. r
Commoiiwealtt of,
f Massachusetts
�a Title 5 Official Inspection. Form' '
X;. .� 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
275 Oxford Dr
Property Address
Christopher Sherman
Owner Owner's Name
information is required for every Cotuit MA 02635 10-28-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) f
a
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
• w
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. r
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):
b• .
t5iru.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts ;-�,<- -: ��;ft: , �'•:--• _ '; r{ {
=1 Title 5 Official Inspection Fount
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
� sr
'� a_�;!✓ 275 Oxford Dr
Property Address r ,
Christopher Sherman ,y - r:;i r' , ;h•,-,
Owner Owner's Name
information is required for every Cotuit MA 02635 10-28-17'
-
page. City/Town I P - State Zip Code Date of Inspection
B. Certification (cont.) , F`_
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
x "pumps/alarms are repaired:
6 4- ,t ¢'. rI '� a,#...r • s. .
B) System Conditionally Passes (cont.):
'Observation of sewage"backup or breakout or high static watervel le in the distribution box due
to broken or obstructed pipes) or due to a broken, settled'or urieve'ri distribution box. System will
`pass inspection if(with approval of Board'of Health):
❑ ' `�liroken pipe(s) are replaced'' +�� ; ❑`Y' '❑ N, �❑ AND (Explain below):
'El ' 1``1-obstruction is removed "'' ;❑Y Y 0 fN �r❑ ND (Explain below):
❑ distribution box is leveled or replaced' "❑ -Y'El' N"'�E❑ 'ND (Explain below):
• '�' ♦;. .ai .,s '„� "j. 'Na •, is+ -fF. `'"tan ",7 f` . r. i t :1, ',C.t."1 �,: A+ "'
' , - 37 'i. .t'4 r 1 t.N. ..,v /. . - { `i5C ri 4 :-•1` `[-,�,'1. ,
.t •. .. io. ' atq,..•.i�.tt ,.., `s.,...^ : ..y: ,s.'.�.r .�'.t' ..'I/ .,"'xE' I"
t; Y.
❑ 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: rF ;A
❑ 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. "
System will pass unless'Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is'not functioning ini a manner which will protect public health,
safety and the environment:
'' ' ` - ❑ Cesspool'or privy is within 50 feet of a surface'water ,
v ❑'' '' 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
•
Commonwealth of Massachusetts
} p Title 5 Official Inspection Form
l` 51 Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
J§ 275 Oxford Dr '
Property Address
Christopher Sherman
Owner Owner's Name
information is required for every Cotuit MA 02635 10-28-17
page. City/Town 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: 'S
❑ 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 asses if the well water analysis, performed at a DEP certified laboratory, for fecal
Y P Y � P rYr
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:
Y
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
r
• Commonwealth of Massachusetts F ;.,'r ►, r..
a f Title 5 Official Inspection Form
' , 14 Subsurface Sewage Disposal System Form Not for Voluntary Assessments '
275 Oxford Dr -
Property Address
Christopher Sherman -_ ►
Owner Owner's Name
information is required for every Cotuit MA 02635 10-28-17:-
page. City/Town r. State Zip Code Date of Inspection
B. Certification (cont.)
_Yes• No . ,r
❑ ® 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.
1 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
="` ' '`tributary to a surface water supply. Y' ` -
y ❑ ® • ,= Any portion,of a cesspool:or privy is within a Zone 1 of a public well.
` r ❑ ' ® •-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 106 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
.•,. ; r } 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-
t ❑ ® _ 10,000gpd: ) • ,.
- r•
r The system fails.',l have determined That one or more of the above failure
❑" ' t® ' "" '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.
}: •� �. { 1 _
For large systems, you must indicate either"yes" or;`no",to each of the,following,,in addition to the
questions in Section D.,.,., F. . t..y a .;,
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, '❑ Area•—'IWPA) or a mapped Zone II of aApublic 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.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
+. A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e,
275 Oxford Dr
Property Address
Christopher Sherman
Owner Owner's Name
information is required for every Cotuit MA 02635 10-28-17
page. City/Town State Zip Code Date of Inspection
C. Checklist ' .
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® ;Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions: t
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based.on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
, Commonwealth of Massachusetts J
:a=1 Title 5 Official Inspection Forth '
` ` Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments ++ `
275 Oxford Dr r,
Property Address
Christopher Sherman
Owner Owner's Name
information is required for every Cotuit ' ' MA 02635 10-28-17,
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
�.'*`� :t,:.,,,.'-, 'ter •;,� :' '
r'P.
- Number of current residents: 1
Does residence have a garbage grinder?.a ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection , El Yes ® No
information in this report.) ` ' w
Laundry system inspected? j + _ +_. ❑ Yes ® No
Seasonal use? < ,, +,-, •d. +z ` r: - tt: t ° . ❑ Yes ® No
Water meter readings, if available.(last 2 years usage (gpd)):, f ,
Detail:
Sump pump? >� s ,•f�; a * ,,,,,t*. ❑ Yes ® No
Last date of occupancy: k�, +I.+ 10-2017Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
•Design flow(based,on,310 CMR.15.203): ,,
Gallons per day(gpd)
^r -: Basis of.design flow(seats/persons/sq.ft.;.etc.): r-+
'l +', .{` . c r= + r .. , .;?y �+ •t,t, _. . f .f .� s,..+.t. L t... . ' a'a
Grease trap present? x ; yw �; ?�. +� + . ��+`� frlr n ❑ Yes ❑ No
Industrial waste holding tank present? L r r x ;I f.,:.,. El Yes El No
Non-sanitary waste discharged to the Title 5 system?' . , ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Off iciat Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17'
, Commonwealth of Massachusetts
ICI Title 5 Official Inspection Form'
l 'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�_J§ 275 Oxford Dr
Property Address
Christopher Sherman
Owner Owner's Name
requir atifo is Cotuit MA 02635 10-28-17
required for every
page. City/Town 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: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: I
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. t
❑ Other(describe):
t5insAoc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts « .,• t + : x
�a� f Title 5 Official Inspection Foem.
-
�' ,.N Subsurface Sewage Disposal System Form Not for Voluntary Assessments
275 Oxford Dr
Property Address
Christopher Sherman r•� <."
Owner Owner's Name 1
information is Cotuit 'x MA 02635 10-28-17 .
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) , s: f►
Approximate age of all components, date installed (if known) and source of information:
1980's with trench added later
, aY Fri,: .- - a'.3•r•p{• Y.. .: ', • � '
Were sewage'odors detected when arriving at the site? El yes ® No
Building Sewer(locate on site-plan):
Depth below grade: ,' r� ,:n : . ,.�, +'• . f' 2411
feet
Material of construction: t+ ,.•�n ;
' ® cast iron ® 46 PVC El other(explain):
,L t -
r 'A
Distance from private water supply well or suction Yline:, feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan): -
Depth below grade: fs. ., r
18"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass 0,polyethylene ❑ other(explain)
♦ . t �, A .i • _ .. .. r ..., +..•.q III
If tank is metal, list age: -
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: ;; , - 1000 gal
1211
Sludge depth:.
t5ins.doc•rev.6/16 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
� Title 5 Official Inspection Form
I�ai f
I< �.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
275 Oxford Dr
Property Address
Christopher Sherman ,
Owner Owner's Name
information is Cotuit MA 02635 10-28-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) . . .
Septic Tank (cont.) - I . ,
Distance from top of sludge to bottom of outlet tee or baffle
20" •
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tapr
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Will r.� Title 5 Official Inspection FostlnF �.�.
I Subsurface Sewage Disposal System Form Not for Voluntary,Assessments.:
p_s,! 275 Oxford Dr
Property Address
Christopher Sherman t, •,�q ! ,u
Owner Owner's Name +
information is Cotuit ' ;,`':• ` MA 02635 10-28-17
required for every
page. City/Town •; State Zip Code Date of Inspection
D. System Information (cunt.) j r , �;f ,. •�.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,'etc')
yr. �, Y. t ,f -^� ri l' ''' f I' r'•��``i:a,r r'[T s+.r ;i' lTb'r:��t,` S �f'°.�
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'
r , Design Flow: ^ t 5: tr., ,, Y .,,
gallons per day r
5
Alarm present: - ❑ Yes ❑ No
Alarm level Alarm in working order: -❑ Yes ❑ No
Date of last pumping: Date
Comments (conditionof alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17•
Commonwealth of Massachusetts +
f Title 5 Official Inspection Form
-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
275 Oxford Dr
Property Address
Christopher Sherman ..
Owner Owner's Name
information is required for every Cotuit MA 02635 10-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Good condition with water at working level and no sign of back-up from fields.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ 'Yes ❑ No*
Alarms in working order:., El, Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
' I
* 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 n :�.: . ~•
Title 5 Official Inspection Forum
�- Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
275 Oxford Dr ;' T
J Property Address r.
Christopher Sherman
Owner Owner's Name F
information is ~ '�`"
required for every COtUIt ' ' MA 02635 10-28-17.-
page. City/Town , State Zip Code Date of Inspection
D. System Information (cont.) : r
Type:'
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1-60'x4'x2'
❑ 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.):
Leach pit in good condition and empty at inspection. Leach trench was video inspected and found no
sign of back-up.
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.6116• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
, Commonwealth of Massachusetts
i+
Title 5 Official Inspection Form
t; A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
275 Oxford Dr
Property Address
Christopher Sherman
Owner Owner's Name
requiratifo is Cotuit MA 02635 10-28-17-
required for every
page, 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.):
s
f +t r
t5ins doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
dl
Commonwealth of Massachusetts 2,
Title 5 Official Inspection Form'
I Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments *.
275 Oxford Dr \ -
Property Address
Christopher Sherman
Owner Owner's Name {
information is Cotuit MA 02635 10-28-17,1
required for every
page. City/Town ., 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
13
_ •°if �h) it". 1{.r,",.,s1. f' C 1 y i. t,' yl.� sv �°.
'l
!. I�• 1J V4�t' i.r \.'l.,t. '. r �y f�� V°+ a 1
1P
_��r.r� rrriw. 1 roes rls��
.A
3W- do
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of,17T
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1, I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
275 Oxford Dr W
Property Address
Christopher Sherman
Owner Owner's Name
information is required for every Cotuit MA 02635 10-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:, i
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12' M
1
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 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)
i
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 12'.
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
�a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�;!✓ 275 Oxford Dr
Property Address ' --„
Christopher Sherman
Owner Owner's Name
information is required for every Cotuit MA 02635 10-28-17
page. 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 All 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
M
DEPARTMENT OF ENVIRONMENTf�,L PROTECTION
a � d
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ?
Property Address: 275 OXFORD DRIVE COTUIT, MA 02635 C)
Owner's Name: KYNOCK
Owner's Address: 275 OXFORD DRIVE COTUIT, MA 02635 RECEIVE®
Date of Inspection: 3/21/02
MAR 2 8 2002
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS TOWN of BARNSTABLE
Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 HEALTH DEPT.
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
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 Furthe aluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 3/21/02
The system inspector shall submit 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 now 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
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****This report only describes conditions`at the time of inspection and under the conditions of use at that lime.'Phis
inspection does not address how the system will perform in the future under the same or different conditions of use.
c/I,-i'nnn i
Page 2 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 275 OXFORD DRIVE COTUIT, MA 02635
Owner: KYNOCK
Date of Inspection: 3/21/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Sectio+ D'
A. System Passes:
X 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:
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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 replacementor repair,as approved by the Board of Health, will pass..
Answer yes, no or not determined(Y,N,ND) in the • for the following statements. If"not determined"please explai-A.
n/a 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 replac.ed
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: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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):
x broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 275 OXFORD DRIVE COTUIT,'MA 02635
Owner: KYNOCK
Date of Inspection: 3/21/02
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
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 I00'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 l 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 n/a
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or-less than 5 ppnl, provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.. _
3. Other:
n/a ,
{
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 275 OXFORD DRIVE COTUIT, MA 02635
Owner: KYNOCK
Date of Inspection: 3/21/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
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 town 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 %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 HASN'T BEEN PUMPED IN THREE YEARS_.
X Any portion of the SAS,cesspool or privy is below high ground water 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 at a DEP
certified laboratory,for c.oliform 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 forma'
(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
_ X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ X the system is located.in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped
Zone 11 of a public water supply well
I 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 CM 15.304. The system owner
should contact the appropriate regional office of the Department. -
i A d
Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 275 OXFORD DRIVE COTUIT,MA 02635
Owner: KYNOCK
Date of Inspection: 3/21/02
Check if the following have been done. You must indicate "yes".or"no"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant, or Board of Health
X Were any of the system components pumped out in the previous two weeks
X Has the system received normal flows in the previous two week period? -
X Have large volumes of water been introduced to the system recently or as part of this inspection'?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage backup
f :
X Was the site inspected for signs of break out
X Were all system components,'excluding the SAS, located on site'?
X 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
X _ 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:.
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ 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)]
m
Ij
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 275 OXFORD DRIVE COTUIT, MA 02635
Owner: KYNOCK
Date of Inspection: 3/21/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x-#of bedrooms): 330.-
Number of current residents: 3
Does 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): NO
Seasonal use: (yes or no); NO
Water meter readings, if available(last 2 years usage(gpd)):it42opp- L, CflpX)0
Sump pump(yes or no): NO 20U I ' SS a0O
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no):NO.,
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: HASN'T BEEN PUMPED IN THREE YEARS.
Was system pumped as part of the inspection(yes or no): NO
If yes, volume pumped: n/agallons-- Flow-was quantity pumped determined? n/a
Reason for ptunping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system .
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and nrxlintenance.contract(to be obtained from
system owner)
_Tight tank °Attach•a copy:of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1980 BY OWNER WITII NEW TRENf 11 IN 1997
Were sewage odors detected when arriving at the site(yes or no): NO
r '
Page 7 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE_ SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 OXFORD DRIVE COTUIT, MA 02635
Owner: KYNOCK
Date of Inspection: 3/21/02
BUILDING SEWER(locate on site plan)
Depth below grade:30"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 24".
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10""
Sludge depth: 2"
Distance from top of sludge'to bottom of outlet tee or baffle: 32"
Scum thickness: I" a
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
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.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal fiberglass_polyethylene_other(explain):n/a
Dimensions: n/a _
r
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert, evidence of leakage,etc.):
n/a
f°
Page 8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 OXFORD DRIVE COTUIT, MA 02635
Owner: KYNOCK
Date of Inspection: 3/21/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site plan) J
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenanres,etc.):
n/a
e � '
Page 9 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 OXFORD DRIVE COTUIT, MA 02635
Owner: KYNOCK
Date of Inspection: 3/21/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required),
If SAS not located explain why:
n/a ,
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
1 leaching trenches, number, length: 60
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system .
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.):
LEACH PIT AND NEW TRENCH ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. t1oTTOM
IS AT 8' AND PIT IS CURRENTLY EMPTY.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool:.n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a r
Depth,of solids:n/a t'
Comments(note condition of soil, signs of hydraulic'failure,`level of ponding,coa it on of vegetation,etc.):
n/a
i
Page 10 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: 275 OXFORD DRIVE COTUIT,MA 02635
Owner: KYNOCK
Date of Inspection: 3/21/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building. ,
y
-
0 ecG
O
AA
4 all ;
AC
All) �
CA 3�
in
Page I I of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 OXFORD DRIVE COTUIT, MA 02635
Owner: KVNOCK
Date of Inspection: 3/21/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet.,.
Please indicate(check)all methods used to determine the high ground water elevation:
YES Obtained from system design plans on record- If'checked,date of design plan reviewed:3/21/02 '
NO Observed site(abutting property/observation hole'within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established.the high ground water elevation:
ENGINEERED PLANS- 12+ FT. _
{
Fr
},c
i
II
COmmo veafth of MOSSOCtwsetts John Grad
EXecutNe Offit;;e of ErMrorVTl Intol Affdrs D.E.P. Title V Se t' •Ins ector
®apartment of P.O. le ,
Environmental Protection Tea 02
s6,,�,6s13
yyo �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM m d�l
PART A ti�9r j�
CERTIFICATION
Property Address: 276 Oxford Dr.COtuit Address of Owner: r
Date of Inspection:3117197 (If different)
Name of Inspector:John Gracl Kynock;Box 1614 Cotult Ma.02635
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The Inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes This Inspection Is based on criteria defined In Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Fu a Evaluation B the Local Approving Authority performing at the time of the Inspection.MV inspection does
y PP 9 ty not Imply any warranty or quarantee of the longevity of the
X Fails septic system and any of Its components useful life.
Inspector's Signature: l ✓ t Date: 3126197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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.
� 7, 130
INSPECTION SUMMARY: 0 a0V
-7
n
Check A,B.C,or D: / O
A] SYSTEM PASSES:
_I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated 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,no,or not determined(Y, N,or ND). Describe.basis of determination in all instances. If "not determined", explain why not.)
The septic tank Is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent.The system will pass inspection If the existing septic lank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1 �-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A
CERTIFICATION(continued)
Property Address: 275 oxford Dr.Cotult
Owner: Kynock;Box 1614 Cotult Ma.02635
Date of Inspection:3117197
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health):
broken pipe(s)are 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 detennine if the
system is failing to protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE 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 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within 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 volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
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 in facility or system component due to an 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
cesspool.
X SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 275 Oxford Dr.Cotult
Owner: Kynock;Box 1614 Cotult Ma.02635
Date of Inspection:3N7197
D]SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
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 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. 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 large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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 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 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115195)
. 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 275 oxford Dr.Cotult
Owner: Kynock;Box 1614 Cotult Ma.02635
Date of Inspection:3117197
Check if the following have been done:
X Pumping information was requested of the owner,occupant,and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
NaAs built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was Inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with Information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4 .
IL
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 275 Oxford Dr.Cotult
Owner: Kynock;Box 1514 Cotuit Me.02635
Date of Inspection:3117197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: Na
Last date of occupancy: i week ago:previously 4 people lived there
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: rda
Last date of occupancy: rda
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped on March 3rd by MacComber Tank only
System pumped as part of inspection:(yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
R Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1980
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
, 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 0xrord Dr.Cotult
Owner: Kynock;Box 1614 Cotult Me.02635
Date of Inspection:3117197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 2'
Material of construction:X concreate_metal FRP_other(explain)
Dimensions: L 8'6'H 5'7" W 4'10"Tank empty
Sludge depth:0
Distance from top of sludge to bottom of outlet tee or baffle: 0
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:0
Distance form bottom of scum to bottom of outlet tee or baffle:0
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.)
Septic tank and all components are structurally sound Recommend pumping system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP other(explain)
Dimensions: rda
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n►a
Distance from bottom of scum to bottom of outlet tee or baffle: nla
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.)
n1a
(revised 11115195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 Oxford Dr.Cotult
Owner: Kynock;Box 1614 Cotult Me.02635
Date of Inspection:3117197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of construct!on:_concrete_metal_FRP_other(explain)
Dimensions: We
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n1a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution Is equal,evidence of solids carryover, evidence of leakage into or out of box etc.)
We
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
We
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 oxford Dr.Cotult
Owner: Kynock;Box 16%Cotult Me.02635
Date of Inspection:3117197
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:n/a
teaching galleries,number: We
leaching trenches,number,length: rVa
leaching fields,number,dimensions:n1a
overflow cesspool,number:n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
The leach pit was full and is past the effective depth of leaching.The system Is In hydraulic failure.
CESSPOOLS:
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert:n►a
Depth of solids layer: nta
Depth of scum layer: n1a
Dimensions of cesspool: We
Materials of construction: nla
Indication of groundwater: Ma
inflow(cesspool must be pumped as part of inspection)
n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n1a
PRIVY:
(locate on site plan)
Materials of construction: n1a Dimensions: nfa
Depth of solids: n►a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla
(revised 11115105)
8
l '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 27S Oxford Dr.Catult
Owner: Kynock;Box 1614 Cotutt Ma 02635
Date of Inspection:3117107
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
SI
O A
a �
A P
Ag 46
At W
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9 '
TOWN OF BARNSTABLE
LOCATION 2 SEWAGE # 3
YILLAGE C,c� �y ASSESSOR'S MAP & LOT 611 0 3y
INSTALLER'S NAME&PHONE NO. 13b N 2nt6 e wt l COG,7'?
SEPTIC TANK CAPACITY l 000 (9)�,(
LEACHING FACIL=: (type) -r IR r ti C td (size)ulo-a
NO.OF BEDROOMS -3
BUILDER OR OWNER Lem
PERMITDATE: - I S • 9 7 COMPLIANCE DATE: - 2 S"-
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�rr1'
�= Q
��iLGG 0 x� p
No. 13D y Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for Dizpozal *p!tem Construction Permit
Application for a Permit to Construct(,)<epair(r )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. oL'7S C>K Fort o a/t I a.e Owner's Name,Address Land Tel.No.
Assessor's Map/Parcel Les Li 4L V,YA)0 tV,
Installer's Name,Address,and Tel..No. Designer's Name,Address and Tel.No.
A6N) GAw9ehv(
;VO 01a (14Y '12O MA-4 h
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 330 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /00 y Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Tw 1'44( 1 ei4 cat I s�S I/LV.uC
60,
.y
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by t ' Board of Health.
Signed Date /�/�77
Application Approved by D Date
Application Disapproved for the following reason
Permit No. J Date Issued
4-
t i i ���
i
� No. � �' " ...-. �:� . ;i Fee 6�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes °
- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpprication for Migo!gal by.5tem Construction i3ermit
Application for a Permit to Construct(w-jRepair(i )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.a S Q K FOn 12 Ott I U-Q Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ._ L e S L!e S(h1 p k
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. j
� AwyPmr
41A S h P�GP0'
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
i
Design Flow 31 U gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /00 O Type of S.A.S.
- Description of Soil
'i
i
Nature of Repairs or Alterations(Answer when applicable) r'� �'`�A /e A c�t i /tn•u C ��
V, �/ Ko�
i
Date last inspected: j
• .�k t try..
Agreement. a -�
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by tj;kis Board of Health.
Signed ` b f/ Date
Application Approved by P D Date
Application Disapproved for the following reaso /
` Permit No. Date Issued law v
---------------------- �•
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
1
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System.Constructed( )Repaired( )Upgraded( )
Abandoned( )by
i
at -hastri constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. V I "~ dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date `�i - Z t` Inspector
E
lly -----------------------.---
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
1=igpoga1 *p6tem Construction permit
Permission is hereby granted to onstruct(, /&pgrade( I don( 6�)rro
System located at J
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or.special conditions.
� C
Provided:Con trultion mus eco pleted within three years of the date of th�sNet.
Date: � / Approved by
/��1 U'v r
4
Yylr �►
NOTICE: This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
t
I, J?C,�,IOAJ Co 6'" (, hereby certify that the application for disposal works
construction permit signed by me dated 3/��/� 7 , concerning the
property located at ,2 7 5— OK (;nm�O D 91 u`ems— meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
�
r DATE:
SIGNED : ��l/�"i' - C� )^G�'�-�/h' —
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
jxert
TOWN OF BARNSTABLE
LOCATION
ter' SEWAGE # J 3
VII-CAGE L, �
ASSESSOR'S MAP& LOT > �3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 600
LEACHING FAC]Lny: (type)
NO..OF BEDROOMS 3 (size)(9c� SQSI fc
BUILDER OR O7ittCOMPLUNCE
PERMITDATE: DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by Feet
i
J
J
-S' 4- •
v
4%
Q � J �
e �
No.._....... 1... =a T Fps.
�.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH ,
wY......................oF..............AAfje).S.r.1-4--4--&................................
Appliratila(n for Disposal Works Tonstrurtion Prrmit
Application is hereby made for a Permit to Construct (jel") or Repair ( ) an Individual Sewage Disposal
System at:
.............. P.r__.�....al................_---•........._
Location-Address ! or Lot No.
1!� Q,r .e�.....1�s1 _6111-1 ................. -- .............................
Owner, Address
a ... l�ew ....�C,�tm. ......................................... ....... .... .�n..........MAI v-----------------------....
Installer Address
Type of Building Size Lot....Z.2k,.i/dP_,$'._Sq. feet
Dwelling—No. of Bedrooms..............\3........................Expansion Attic (✓f Garbage Grinder (04)
Other—T e of Building No. of persons............................ Showers
a YP g --------------------------•- ------- ( ) — Cafeteria ( )
Otherfixtures -----•-----------•------------•---------- •---------••--•---------------- ... ----------
W Design Flow.................�j—.S_..................gallons per person per day. Total daily flow--.....-....�1I-��.........__......gallons.
WSeptic Tank 1 Liquid capacity..I.P.Agallons Length................ Width................ Diameter.........---.--. Depth................
x Disposal Trench—No..................... Width............_....... Total Length.....................Total leaching area.--......._../._.j....sq. ft.
Seepage Pit No......I------------ Diameter...Zo.'.......... Depth below inlet.......(a......... Total leaching area.sa .{o.da__sq. ft.
Z Other Distribution box (14 Dosing tank ( )
Percolation Test Results Performed by-----------------------------•----•----------------------------•--•------- Date........................................
a
Test Pit No. 1.....�..__.minutes per inch Depth of Test Pit.................... Depth to ground water.....................--.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................
..... ---
O Description of Soil s «' �---�_--. .&......2- ------ l -----...... k` -- ,1
V --------_--•---
W -------------------- .................................................................................................................... ...............................................................
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 issued by the board of health.
Signe .__ ....
. --....•-••---------------------------•-•--•--------...-----------
---------------------•-•---•--
Application Approved By..... n e
Date
Application Disapproved for the following reasons-............................... •---------------------•-----....-----------••------•-••-----•----....._...._...
Date
Permit No......................................................... Issued---•j ••-- ------
�ate
No...............
-:�... -n, • Fss. ... . .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
IAZV4a .....................OF.............. .t o 2 3. .q 43 _..............._...............
d
Applir ation for llhipas al Works Tonstrurtiun Prrutit
Application is hereby made for a Permit to Construct ( -.**) or Repair ( ) an Individual Sewage Disposal
System at:
----------------------------• ...................................... _!? "_ ..Lxg...............................
Location-Add or or Lot No.
._... .............. .............................
W Owner, Address
a •---......`�-rP.�"J_-a'-a .e�..�? ,'?-!------------------------------------------ .............. _.._?���'�'?.= .4e..`--•-•---...........................---
Installer Address r
UType of Building Size Lot.... a_..Sq. feet
a Dwelling—No. of Bedrooms..............1�3-_--_----_--___-__-Expansion Attic (Y1 Garbage Grinder (,04)
aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
04 Other fixtures ............-••----------=-----•---•-.....-----------.--•---------•-••----••-•------------- =:..::. --•.
WDesign Flow.................`s_ ...._. .........gallons per person per day. Total daily flow............ .........._.......gallons.
WSeptic Tank 1 Liquid capacity../#. gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.......... .....sq. ft.
Iff
3 ., 0.......... Depth below inlet....._......... Total leaching area.: .�
Seepage Pit No..._._/-._-__-__-- Diameter.._ t_ ..sq. ft.
Z Other Distribution box ( V� Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. I......+�2__.._.minutes per inch Depth of Test Pit.................... Depth to ground water----_--______-__------_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---•--.... j
O ----..............
7_..__
Description of Soil... '"_. �,.- :.U tom.- '� ....................
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 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 issued by the board of health.
Signe .` ....................................v-•--........-•••-•......-•--•.......--•• ................................
J�� I Die
Application Approved By...... G',e IL v ! 1.1 - °�� / �.l'��.
._._ .......
Date
Application Disapproved for the following reasons-................................/.------------------------------------------------------...........••••--
----•--•-••-•...•-•-.........-•---•••••--•-•••-•.....--•.........................•-•••-••---•-••-•------•....=---•---•-•--•------•---•--•------••------•------•••-----••-------•---•---•---•---•-------
Date
PermitNo.......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EAL
i..//.
�rr#if irtt#r of ft�u�t��i�attre �...�
THI IS TO CER IFY, That the Individual Sewage Disposal Sy tem constructed ( ) or Repaired ( )
by -' . .,. .. ........ r 1f= ��
3 alley / /'� '
at. P. - il!'l: �.'.:� —. --- .. d Jam_ �, > �._....�.....
= A. ,/� _
has been installed in accordance witl�dtlie provisions of T Fl 5 df�The State Sanitary Co e as des�b din the
T
application for Disposal Works Construction Permlt o. _
- ---.-�-.�-�------•---. dated---.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON ED AS A GflJARANTEE THAT THE
SYSTEM WIL FUNCTION SATISFACTORY.
DATE:.. - --------------------- Inspector
_ .............................
y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALT
1 .....OF.............. -''fr J'... .....l ...r....
-... .... FEE... ...........
��atilaat rrarti
- l
Permissi is�k reby granted.---- -y r ' ;' .._< xx. ........
to .Constr ( ) or Repair �) an/Ind id'ual Se �a'g is�osal S � `
....- --v- . - ------.
/` Street �f u
as shown on the application for Disposal V7orks Construction Pegaffig No..... ..f'/` Dated_.-.0----------
�•-----(-i----•------
•___.....__..e:::_ P, r �C".._,�'/'Y G^: T.'.'.'�.A.....:................. 1.
' r DATE 14 Board of health
� .. ----------------• ;
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
t
..,..,..
57.5
Aw
55fi3r
,E.0
Lpvc r
3.7�
4 cZ c�a a—S emsz:'o �f� �_oaJc . Luv-o Nc, P+-.
100��?Gat. CoN�
SL�Tie. TANv- a
4-(p,5 ,® � > 1fZ'wQSltidfA �jFOMC
F3ar r r E-L
DesM.Cow6,7-lotJ
�T '. Zr� (rJ � Ncr� D�2 �F
T sr peeV. _ME:(> 0
c�R,00 m CgFD = 33o GPro Lea"'(n
30 Fo �.- U5 I o o���-, .� � 1c` 'aNK
PAC i-r,-f"Piz av t cat.a
IBOrraK — ) o xkoK1 , 0 = I oo C- P-D
1T 4 �� � b ? = boo C= PP
!.. CA ra PQo u�PET; r7 o o G PC1
SA�j D
'F""'►+�-�' �A fl SS � �.1►,}V r k'dAa M8M rA L. .
s (�
14-10
TE s s L-o T- 30k 10 E7 S 66WT
Z2
�v �•A, 2a,4-S�s� yi �
o Rj
C.a
✓„�� roe (�'^llvt'tf3
r 3BEDQDDj],00061AL,
AR IN
Nz
� �1 -1
j
�� ,i.. ,,.;�:. `��;�:•/- --z '` ��5 0�, � �C Cam`%t�y �, _��
.� 1
LOCATION SEWAGE PERMIT 10.
VILLAGE
cofV
INSTA LLER'S NAME A ADDRESS
_ f/� L'I XI
CLEDZI a ST 0, AANW9 10
UILLDEIt OR OWNER
j
vC` u
DATE 'PERMIt ISSV E D
DATE COMrPLIANCE ISSUED l( -- ar—d °
n
O. � '��
,, �
�G
I
R �
` '� f
i
s' . �.
LOCATION ? SEWAGE PERMIT NO.
-VILLAGE
a INS LLER'S ME i ^A00 E S S
R U DER OR ..
11�
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED v1—
� w
r�'