HomeMy WebLinkAbout0033 OYSTER PLACE ROAD - Health 33 Oyster Place Rdgd,Cotuit
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Notice of Alternative Sewage Disposal System
M.G.L. c. 21A, § 13 and 310 CMR 15.0287(10)
This Notice to be recorded and/or filed for registration in the chain of title of the Property served by an Alternative
ewage Disposal System("Alternative System").]
NAME(S) OF OWNER OF PROPERTY SERVED BY ALTERNATIVE SYSTEM: Matthew J. !
Mackinnon Trustee 33 Oyster Place Realty Trust Cotuit,MA. 02635 c/o MCCM Realty Trust,P.O. Box
152 Hinjaham,MA 02043 i
i
ADDRESS OF PROPERTY SERVED BY ALTERNATIVE SYSTEM: 33 Oyster Place Road, Cotuit,
MA 02635
TITLE REFERENCE FOR PROPERTY SERVED BY ALTERNATIVE SYSTEM [check and
complete each that applies]:
X Deed recorded with the Barnstable Registry of Deeds in Book 32388,Page 322
_Certificate of Title No. issued by the Land Registration Office of the Registry District
_Source of title other than by deed
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[If Alternative System Owner(s)is other than Property Owner(s),complete the following:]
Alternative System Owner Name:
Alternative System Owner Address:
WHEREAS, Section 15.280 of Title 5 of the State Environmental Code("Approval of
Alternative Systems"),provides for the Massachusetts Department of Environmental Protection(the .
"Department")to approve or certify,as appropriate,all proposals to construct, upgrade or replace on-site
sewage disposal systems using alternative systems; j
WHEREAS,owners and/or operators of approved or certified alternative systems are subject to
general conditions,as specified in Section 15.287 of Title 5 of the State Environmental Code, 310 CMR i
15.287, and may be subject to special conditions, as specified in the Department's approvals or
certifications; such general and special conditions potentially including,without limitation,requirements 1
relating to the use of trained operators,periodic inspections,maintenance, sampling,reporting and/or
recordkeeping;
WHEREAS, Section 15.287(10) of Title 5 of the State Environmental Code, 310 CMR
15.287(10),requires that"prior to obtaining a Certificate of Compliance for installation of a new or
upgraded system,the system owner shall record in the chain of title for the property served by the 1
alternative system in the Registry of Deeds and/or Land Registration Office, as applicable,a Notice
disclosing both the existence of the alternative on-site system and the Department's approval of the
system. The system owner shall also provide evidence of such recording to the local Approving
Authority [;]"and
WHEREAS,the Property is served by an alternative sewage disposal system. 3
NOW,THEREFORE,Notice of an alternative sewage disposal system is hereby given for the
I
above-referenced Property, as follows:
1. Existence. An alternative system has been installed as a new or upgraded alternative sewagedisposal
system, on or adjacent to the Property, and serves the Property. The trade name and model number(s) of
the alternative system are as follows:
Trade name of technology: NitROE® Waste-Water Treatment System
Manufacturer Name: K1eanTu®LLC I
Model number(s): NitROE®2KS W WTS
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Page 1 of 2
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2. Approval/Certification. On May 12,2020 [datel,the Department,pursuant to its authority
under the section of Title 5 as specified below, approved or certified the technology used in the above-
referenced alternative system,under MassDEP Transmittal Number: X285590 iTransmittal Number of
approval or certification].
[Check one of the following,as applicable:]
Approved for remedial use under 310 CMR.15,284
Approved for piloting under 310 CMR 15.285
X .Provisionally approved under 310 CMR 15.286
Certified for general use under 310 CMR 15.288
A copy of the Department's Approval/Certification is available from the Department in person or on-
line at the Department's website: http://www.mas ov/de
WITNESS the execution hereof unde4[Alteriv
da} of 0C+06Q C ,2021,made by
the above-named Alternative System Owner(
i
stem Owner(s)]
): "T'HCyJ ::7. ►MQ<I kWb��
STATE OF NEW HAMPSHIRE
Y^ n ;ss
On.this IQ .day of 2021,before me,the undersigned notary public
� �����pnnugll�l
personally appeared A<, �,t `;�° name of document signer),proved to me througl 11jefi ,11"i",�
evidence of identification,which were VI fi. l ,to be the person,�5e n 'is.e
e that e sr h
signed on the preceding or attached document,and.acknowledged tom (h ) ( � g �Q� o;w r i
voluntarily for its stated purpose.
_ o
o d` . ..a=
cia signature atia seal of notary) %�� '•.,,,n�o----------------
, ,pA'? P��°•`
(Complete the following Property Owner(s)Consent if Alternative System Owner(s)is other than the�l�bt1
Owner(s):]
CONSENTED TO:
(Property Owner(s)]
Print Name(s):
Date: g
COMMONWEALTH OF MASSACHUSETTS =
ss
On this day of _,2021,before me,the undersigned notary public,
personally appeared (name of document signer),proved to me through satisfactory
evidence of identification,which were ,to be the person whose name'is
signed on the.preceding or attached.document, and acknowledged to me that.(ho)(she)signed it
voluntarily for its stated purpose,
(official signature and seal of notary)
Upon recording,return to:
Matthew J. MacKinnon,Trustee,c/o MCCM Realty Trust,P.O.-Box 152,Hingham,MA 02043
Page 2 o172 BARNSTABLE-REGISTRY OF DEEDS ,
John.f...Meade, Register
01-19-20322
Notice of Alternative Sewage'Disposal System
M.G.L. c. 21A, § 13 and 310 CMR 15.0287(10)
This Notice to be recorded and/or filed for re;istration in the chain of title of the Property served by an Alternative
ewage Disposal System ("Alternative System ).] j
NAME(S) OF OWNER OF PROPERTY SERVED BY ALTERNATIVE SYSTEM: Donald J.
Mackinnon Trustee MCCM Realty Trust
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ADDRESS OF PROPERTY SERVED BY ALTERNATIVE SYSTEM: 910 Main Street,Cotuit,MA
02635
TITLE REFERENCE FOR PROPERTY SERVED BY ALTERNATIVE SYSTEM [check and
complete each that applies]:
X Deed recorded with the Barnstable Registry of Deeds in Book 32145,Page 257
_Certificate of Title No. issued by the Land Registration Office of the Registry District
_Source of title other than by deed
[If Alternative System Owner(s)is other than Property Owner(s),complete the following:]
Alternative System Owner Name:
Alternative System Owner Address:
WHEREAS, Section 15.280 of Title 5 of the State Environmental Code ("Approval of t
Alternative Systems"),provides for the Massachusetts Department of Environmental Protection(the
"Department")to approve or certify, as appropriate, all proposals to construct,upgrade or replace on-site
sewage disposal systems using alternative systems;
WHEREAS, owners and/or operators of approved or certified alternative systems are subject to
general conditions, as specified in Section 15.287 of Title 5 of the State Environmental Code,310 CMR
15.287, and may be subject to special conditions, as specified in the Department's approvals or
certifications; such general and special conditions potentially including,without limitation,requirements
relating to the use of trained operators,periodic inspections,maintenance, sampling,reporting and/or
recordkeeping;
WHEREAS, Section 15.287(10) of Title 5 of the State Environmental Code, 310 CMR
15.287(10),requires that"prior to obtaining a Certificate of Compliance for installation of a new or
upgraded system,the system owner shall record in the chain of title for the property served by the
alternative system in the Registry of Deeds and/or Land Registration Office, as applicable, a Notice
disclosing both the existence of the alternative on-site system and the Department's approval of the I
system. The system owner shall also provide evidence of such recording to the local Approving j
Authority [;]" and
WHEREAS,the Property is served by an alternative sewage disposal system.
NOW,THEREFORE,Notice of an alternative sewage disposal system is hereby given for the I
above-referenced Property, as follows:
1. Existence. An alternative system has been installed as a new or upgraded alternative sewage disposal
system, on or adjacent to the Property, and serves the Property. The trade name and model number(s) of
the alternative system are as follows:
Trade name of technology: NitROE® Waste-Water Treatment System
Manufacturer Name: KleanTu®LLC
Model number(s): NitROE®2KS W WTS i
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Pagel of 2
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2. Approval/Certification. On May 1.2,2020 [date],the Department,pursuant to its authority
under the section of Title 5 as speeif ed below,approved or certified.the technology used in the above-
referenced alternative system,under MassDEP Transmittal Number: X285590 [Transmittal Number of
approval or certification]. 1
[Check one of the following,as applicabled
Approved for remedial use under 310 CMR 15284
Approved for piloting under 310 CMR 15.285
X Provisionally approved under 3.10 CMR 15.286
Certified for general use under 310 CMR 15.288
F
A copy of the Department's Approval/Certification is available from the Department in person or on-
line at the Department's website:hgp://www.mass: ova; /do .
WITNESS the execution hereof under seal this � � day of 0�-+v ,2021,made by
the above-named Alternative System Owner(s). c
j t native 9 st wner(s)l t
Print Name(s):>
COMMONWEALTH OF MASSACHUSETTS
lmwtou-+k ,ss
On this `7 'day of Drktf6e.:r' ,2021,before:me,the undersigned.notaiy public,
personally appeared ,„..)A--f,1`LLkk,.r: 4name of document signer),proved to me through satisfactory
evidence of identification,which were%tsn mA t-1 knawtsi to be the person whose name is
signed on the preceding or attached document,and acknowledged to me that(he) (she)signed it
GE O
RAWINEL-bAVIS`
NTARY PUBLIC (official signature and seal of notary)
COMMONWEAL7H OF MASSACAUSETfS r
`� + I�
-MYCMISSIONEXPIRESON _,_,. 10
wner(s)Consent if Alternative System Owner(s)is other than:, eeo>
Owner(s):) " y.°,� {p•,►u+,
60
T1111
CONSENTED TO: , a "
AT doh.
[Property Owner(s)] yd;.4 Ld��4T
Print Name(s):
Date: r , ► +-'`
COMMONWEALTH OF MASSACHUSETTS
t
ss
On this day of ,2021 before men the undersigned notary public,
personally appeared (name of document signet),proved to me through satisfactory
evidence of identification,which were ,to,be the person whose name is
signed on the preceding or attached document,and acknowledged to me that(he)(she) signed it
voluntarily for its stated purpose.
(official signature and seal of notary)
Upon recording, return to:
Donald J. MacKinnon,Trustee,MCCM Realty Trust,P.O.Box 152,Hingham,MA 02043
Page 2 of 2 BARNSTABLE REGISTRY OF DEEDS
John F. Meade,le.gister
Town of Barnstable
Board of Health
snt MASS.
200 Main Street,Hyannis MA 02601
Mass.
Office: 508-862-4644 John Norman,Chairrman
FAX: 508-790-6304 F.P.(Thomas)Lee,P.E.
Donald A.Guadagnoli,M.D
Daniel Luczkow,M.D.Al
March 4, 2022
Mr. Daniel A. Ojala, P.E., P.L.S.
Down Cape Engineering
939 Main Street, Route 6A
Yarmouth Port, MA 02675
RE: 33 Oyster Place Road, Gotuit A:`035 � 01>
Dear Mr. Ojala,
You are granted variances on behalf of your client, Matthew MacKinnon Trustee
of Oyster Realty Trust, to construct an onsite sewage disposal system utilizing a
NitROE secondary treatment unit with advanced nitrogen reduction technology at
33 Oyster Place Road, Cotuit, Massachusetts.
The following variances were granted:
310 CMR 15.213(i): To install a septic tank within a velocity zone.
310 CMR 15.405 (f): To install a septic tank zero feet away from a coastal
bank, in lieu of the twenty-five (25) feet minimum setback required.
310 CMR 15.405 (f):. To install a NlTroe tank zero feet away from a
coastal bank, in lieu of the twenty-five (25) feet minimum setback required.
310 CMR 15.405 (f): To install a pump chamber zero feet away from a
coastal bank, in lieu of the twenty-five (25) feet minimum setback required.
Section 360-1 of the Town of Barnstable Code: To install a septic tank
zero feet away from a coastal bank, in lieu of the 100 feet minimum
separation distance required.
Section 360-1 of the Town of Barnstable Code: To install a soil
absorption system zero feet away from a coastal bank, in lieu of the 100
feet minimum separation distance required.
Q:WP\0.Ojala 33 OysterPlaceCotuit Variances and NITROE Approval Sept 2021.docx
These variances were granted with the following conditions:
1. The engineering plan shall be revised to show the location of the
waterline.
2. The designing engineer indicated on the submitted plan that there was an
'existing 4 bedroom disposal works construction permit.' Prior to the
issuance of a disposal works construction permit for this proposal, the
Health Division staff shall review historical files to verify whether or not a
four bedroom disposal works construction permit was previously issued at
this location.
These variances were granted because the physical constraints at the site severely
restrict the location of the septic system components due to wetlands and coastal bank
in the area.
You are reminded the following requirements are provided within the MA Department of
Environmental Protection (DEP) Provisional Use Approval Renewal letter for this
particular technology, dated May 12, 2020:
(1) Thirty (30) days prior to submitting an application for a DSCP, the
Company or its representative shall provide to the Approving Authority a
certification, signed by the owner of record for the property to be served by
the unit, stating that the property owner: a) has been provided a copy of
the Provisional Use Approval and all attachments and agrees to comply
with all terms and conditions; b) has been informed of all the owner's costs
associated with the operation including power consumption, maintenance,
sampling, recordkeeping, reporting, and equipment replacement; KleanTu
NitROE 2K Provisional Approval, May 2020 Page 11 of 15 Technology:
NitROE® 2KS & 2KM WWTS c) understands the requirement for a
contract with a company approved operator and has been provided a
current list of all approved operators; d) agrees to fulfill his responsibilities
to provide a Deed Notice as required by 310 CMR 15.287(10) and the
Approval; and e) agrees to fulfill his responsibilities to provide written
notification of the Approval conditions to any new owner, as required by
310 CMR 15.287(5).
(2) Prior to the issuance of a Certificate of Compliance by the Approving
Authority: a) In accordance with 310 CMR 15.021(3), the System Installer
and Designer must certify in writing that the System has been constructed
in compliance with 310 CMR 15.000, the approved design plans, and all
local requirements, including any local approving authority site-specific
requirements;
Q:WP\0 Ojala 33 OysterPlaceCotuit Variances and NITROE Approval Sept 2021.docx
(3) Prior to issuance of the Certificate of Compliance and after recording
and/or registering the Deed Notice required by 310 CMR15.287(10), the
System Owner shall submit the following to the Local Approving Authority:
(i) a certified Registry copy of the Notice bearing the book and page/or
document number; and (ii) if the property is unregistered land, a Registry
copy of the System Owner's deed to the property, bearing a marginal
reference on the System Owner's deed to the property. The Notice to be
recorded shall be in the form of the Notice provided by the Department
(4) Prior to the use of the System, the System Owner shall enter into an O&M
Agreement with a qualified contractor and submit the Agreement to the
Approving Authority and the Company. The Agreement shall be at least
for one year.
(5) The wastewater effluent shall be sampled and analyzed/tested quarterly if
this facility is utilized year-round. Sampling shall include pH, BOD5, TSS
and Total Nitrogen, unless otherwise stated. Flow shall be recorded at
each inspection. [Note: a) Year-round facilities shall be inspected and effluent sampled
quarterly; b) Seasonal properties shall be inspected and effluent sampled a minimum of twice per
year, with at least one annual sample taken 30 to 60 days after seasonal occupancy and a second
sample taken no less than 2 months after the first sample; and c) After 12 rounds of monitoring,
sampling may be reduced to TN only quarterly. Reduced sampling shall also include Field Testing
of System wastewater when determined necessary by the operator, see DEP Field Testing
Protocol at http://www.mass.gov/eea/docs/dep/water/laws/i-thru-z/testsamp.pdf]
(6) A copy of the wastewater analyses, wastewater flow data, field testing
results, and System Operator O&M reports and inspection checklists shall.
be maintained by the Company. It is recommended the System Owner
also maintain copies of these items.
All of the other conditions listed in the MA Department of Environmental
Protection (DEP) Provisional Use Approval Renewal letter to KleanTu LLC dated
May 12, 2020 shall be adhered to.
Sincerely yours,
hn Norman
hairman
Q:WP\0 Ojala 33 OysterPlaceCotuit Variances and NITROE Approval Sept 2021.docx
11� DATE:
$95.00 FEE*: �t
Town of Barnstable
��, REC.BY
Board of Health . .SCHED.DATE:
200 Main Street,Hyannis MA 02601
Office: 508-8624644
John T.Norman.
FAX: 508-790.6304 Donald A.Guadagnoli,M.D.
Paul J.Cannifl;D.M.D.
F.P.(Thomas)Lee,Alternate
VARIANCE REQUEST FORM
LOCATION
Property Address: 33 Oyster Place Road, Cotuit
Assessor's Map and Parcel Number: 35 Size of Lot: 101
Wetlands Within 300 Ft. jles Business Name: .
s
Subdivision Name:
APPLICANT'S NAME: Phone
Did the owner of the property authorize you to represent him or heft Yes No
PROPERTY OWNER'S NAME CONTACT PERSON
Name: Matthew J. MacKinnon, Trustee Name: Daniel A. Ojala, PE, PLS,
. Oyster Place Realty Trust own Cape Engineering, Inc.
Address: 33 Oyster Place Rd, Cotuit, MA 02635 Address:939 Route 6A,Yarmouth Port, MA 02675
Phone:.,.z. Phone: 508-362-4541
EMAIL:_downcape(ndowncape:com
VARIANCE FROM REGULATION oncl.lteg.Code a) REASON FOR VARIANCE(May attach separate sheet if more space needed)
NATURE OF WORK: House Addition House Renovation Repair of Failed Septic System LJ
Checklist (to be completed by office stag-person receiving variance request application)
Please submit first four on list as S collated packets.
_ A. Five(5)copies of the completed variance request form
_ B. Five(5)copies of MA DEP approval letters for Innovative/Altemative septic system(when proposing an VA system or
secondary treatment unit(S.T.U.). .
_ C. Five(5)hard copies of engineered plan submitted(e.g.septic system plans)and one(1)electronic version submitted to email:
health(a?town.bamstable.ma.us *(Pool Plan—5 hard copies)
_ D.Five(5)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)and one(I)electronic
version.
A completed seven(1)page checklist confirming review of engineered septic system plan by submitting engineer or PLS. .
_ Signed letter stating that the property or business owner authorized you to represent him/her for this request
Applicant'must notify abutters by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or
local sewage regulation variances only)
Full menu—Five(5)copies of full menu submitted(for grease trap variance requests only).
Fee Submitted*$95.00 for the following variances: 1)New construction, 2) Septic repairs with increase in flows, and 3)New
owner/new lessee applying for food, pool or body art variances. Exemptions from Variance Fee: 1)Septic repair without an
,I increase in flow and variances granted at the counter,2)Monitoring Plans,and 3)Temporary Food(not a"variance").
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED John T.Norman
NOT APPROVED Donald A.Guadagnoli,M.D.
REASON FOR DISAPPROVAL. Paul J.Canniff,D.M.D.
Q:\Application Forms\VARIREQ Rev Jan 1-2020.docx
939 main street rte.6a tel.(508)362-4541
yarmouth port
mass 02675 fax(508)362-9880
down cape engineering, inc
Daniel A.Ojala,P.E.,P.L.S.
land court civil engineers&land surveyors
surveys Arne H.Ojala,P.E.,P.L.S.
Daniel E.Gonsalves,P.E.,S.E.
Craig J.Ferrari,E.I.T., S.E.
structural design September 10, 2021
site planning
Barnstable Board of Health
200 Main Street
sewage system designs Hyannis, MA 02601
Regards: Septic Upgrade for Matthew J. MacKinnon,33 Oyster Place Road Cotuit
inspections
permits Dear Board Members:
On behalf of our client, enclosed is a variance application request for a 4-bedroom
septic upgrade. We are requesting the following variances:
Title 5 (310 CMR)Variances Requested:
15.213 (1)Installation of a septic tank in a velocity zone
15.405 (If)Reduction in setback, septic tank to coastal bank(25'to 0')
15.405 (1f)Reduction in setback, septic tank to coastal bank(25'to 0')
15.405 (la)Reduction in setback, septic tank to coastal bank(25'to 0')
Barnstable Health Regulations(VIH):
Reduction in setback, SAS to Coastal Bank(100' to 0')&septic tank to
coastal bank(100' to 0')
The new Title 5 septic system upgrade will maintain the same 4-bedroom design flow
and will include the NitROE denitrification system. The purpose of the Upgrade is to
remove the existing leaching out of the coastal bank and velocity zone, provide the
maximum separation to groundwater possible, and install a denitrifying septic to i
protect the adjacent embayment. A far superior environmental protection is achieved
by granting permission to construct the new system.
Thank you for your consideration.
Sincerely,
w
Jt
Daniel A. Ojala, PE, PLS
Down Cape Engineering, Inc.
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September 8, 2021
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Town of Barnstable Board of Health
200 Main Street
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Hyannis, MA 02601
To Whom It May Concern:
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This letter is to verify that I have authorized Down Cape Engineering, Inc.to design a plan for an alterna-
tive septic system to be installed at my house. This plan will be submitted to you for approval.
Please don't hesitate to contact me with any questions at(781)741-5005. j
Si erely,
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Matth J. Kinnon
Trustee or 33 Oyster Place Realty Trust
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33 Oyster Place Road j
Cotuit, MA 02635 I
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c/o MCCM Realty Trust
P.O. Box 152
Hingham, MA 02043
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KleanTull LLC
Joan
KteanTu wastewmer R.Smith
P.Q.Box i1S+i
Treatment Ed awft,MA 02539
TeChn�tac�les � ,rt�
412-719-5976-Mobile
5:08-627-3072-Office
September 9,2021
3
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Town of Barnstable Board ofRealth
200 Main Street
Hyaimis,MA 02601
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RE: Property and System Owner Certification for Now NitROE02KS WWTS EnIninded Title 5 Septic System �
Installation for 33 Oyster Place Road,Cotuit,MA 02635;KleanTu Project#80€i5.I..
Dear Members of the Soarer;
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Kindly refer to the following-, (i)the Mass DEP Provisional Permit issued to,KIcanTu0 LLC(DEP Transmittal No.:
,U8559.0;Issued May 12,2020)(the"11E 1'erntit'};and(ii)the Enhanced Title 5 Septic System proposed for
33 Oyster Place Road,Cowit,MA,a private residence,(the"h'ew S_,ystem),featuring the use of new NitltOE'0
2KS wastewater treatment system(thu`'litROE!2KS C0MR Heats")
item ICJ-#5 of the DEP Porruit requires that KleanTuO LLC provide to the Town of Barnstable Board of health(the
"Boar&)a certification that the owner of the property of record has agreed to certain specific matters with;respect to the E
New System,
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I have included frith this letter the required certification,
Should you have any questions,please do not.lbesitate to contact me:
Sincerely yours,
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John R.5tnith
President
Enclosure
CO. Mathew MacKinnon,Property and System Owner Trustee
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September 9,2021
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KleanTu®LLC
John R. Smith
P.O.Box 1154
Edgartown,MA 02539
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Dear Sir: I
I refer to the following: (i)the Mass DEP Provisional Permit issued to KleanTu®LLC(DEP Transmittal No. X285590;
j Issued May 12,2020)(the"DEP Permit");and(ii)the Enhanced Title 5 Septic System(the"New System')proposed for
` my private residence at 33 Oyster Place Road, Cotuit,MA 02648,featuring the use of a new NitROE®2KS G
wastewater treatment system (the"NitROE®2KS Components").
By signing this letter and delivering it to you,as the owner of the property known as 33 Oyster Place Road,Cotuit,MA
02648, I/we hereby certify to the accuracy of all of the following statements:
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1. I have been provided a copy of the DEP Permit and I agree to comply with all terms and conditions cited therein.
2. 1 have received estimates of all homeowner's costs associated with the Monitoring,Operation and Maintenance I
(M.O.M.)of the NitROE®2KS Components including power consumption and equipment replacement,as well as
maintenance,sampling,recordkeeping, reporting and related matters for the NitROE®2KS Components(collec-
tively,the"M.O.M.Responsibilities.").
3. 1 understand that I must enter into a contract by which my 0&M Responsibilities will be fulfilled with KleanTu®
or a KleanTu®-approved operator licensed by the Mass DEP as required by the DEP Permit.
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4. I understand that I must provide a Deed Notice to the Town of Barnstable Board of Health as required by 310
CMR 15.287(10)and the DEP Permit.
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S. I understand that I must fulfill my responsibilities to provide written notification of the conditions of the DEP Per-
mit to any new owner,as required by 310 CMR 15.287(5).
Sincerely yours, j
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Mathew acKinn n
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Kleaffu°LLC
John R.Smith
KlieanTu 'Wasteviater P.tJ.BOX 1154
Treatment
Technologies Edgartown,i'VMlA 02539
412=719-5376-Mobile
S08-627-3022-Office
September 9 2021
To: Town of Barnstable Berard of Health
200 Main Streit
Hyannis,MA 02601
RE: Designer Certification for New NAROE,02KS W'TS E"anced Title 5 Septic System Installation
for 33 Oyster Place Road,Cotuit,Mel 02635;KleanTu Project#8.O t..
Dear Members of the Board:
Kindly refer to the following: (i)the Mass:I)EP.Provisional I'crtnit issued.to KiesnTijO I,I,C(D.Ep Transm,i.ktal No.:
.K285590;Issued May 12, 2020)(the",DEP Permit"),and(ii)the Enhanced Title S Septic System desigtt for the
33 Oyster Placc Road,Cotuit,MA private residence(the"New System");featuring the use of a stew
NitROL'2KS wastewater treatment system (the`�f�tRt���'2KS Com�onettts°'). The New System was designedby
Daniel A.Ojala,a Massachusetts Registered.Professiocsal Engineer with Dowtt Cape Engineering,Inc.
The N itRQE 2KS Components are depicted in the Site Drawing titled"Site Ilan of 33 Oyster Place'Road",pre_
parch by IDwj.i Cape Ei.i&eering aitcl dated.September 8,202I.
Item IV-42 of the DEP Permit requires that KleattTulmake certain certi catiotts to the Town of Barnstable Board
of Health(the=`Board")pertaining to the design of the New System,
Accordingly,KleccxcTcc'ILLC hereby certifies to the Board that: (i)the New System design,solely as it relates to the
NitR0E1'2KS Components and their incorporation into the New System,conforms with the design specifications
required by the;.DEP Perini,and(i.i)the NitROL- '2KS Components are able to perfbrm the proposed wastewater
treatment for the New,c ystem.
:Sincerely yours,
John It, Smith
President
cc: Daniel A.Qja:la,bowie Cape Engineering
Mathew MacKinnon, Property Lind System Owner Trustee
i
s
-1- _.
o Commonwealth of Massachusetts
Executive Office of Energy &Environmental Affairs
Department of Environmental Protection
One Winter Street Boston, MA 02108.617-292'5500
Charles D.Baker Kathleen A.Theoharides
Governor Secretary
Karyn E.Polito Martin Suuberg
Lieutenant Governor Commissioner
PROVISIONAL USE APPROVAL RENEWAL
Pursuant fo Title 5, 310 CMR 1.5.000
Name and Address of Applicant:
K1eanTu LLC.
300 Old Pond Road, Ste#206
Bridgeville, PA 15017
Trade name of technology and models:
NitROEO Waste-Water Treatment System (NitROE® WWTS) with unit sizing for design flows up to
2000 gpd (NitROE® 2KS WWTS and NitROE® 2KM WWTS) (hereinafter the `System' or the
`Technology'). Owner and Operator manuals, installation manual, schematic drawings illustratingithe
System models and the technology inspection checklist are part of this Certification.
DEP Transmittal No.: X285590
Date of Issuance: May 12, 2020,
Expiration date: May 12,2025
Authority for Issuance
Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000,the Department of Environmental
Protection (hereinafter "the Department") hereby issues this Provisional Approval to: KleanTu LLC,
located at 300 Old Pond Rd., Ste 206 in Bridgeville, PA (hereinafter "the Company"), NitROE® 2KS
WWTS and NitROE® 2KM WWTS (hereinafter "the Technology" or "System") for use in the
Commonwealth of Massachusetts subject to the conditions herein. Sale and use of the Technology is
subject to compliance by the Company, the Designer, the System Installer, the Operator, and the System
Owner with the terms and conditions herein. Any noncompliance with the terms or conditions of this
Certification constitutes a violation of 310 CMR 15.000.
MU 12,2020
Marybeth Chubb, Section Chief Date
Wastewater Management Program
Bureau of Resource Protection
4
This information is available in alternate format.Contact Michelle Waters-Ekanem,Director of Diversity/Civil Rights at 617-292-5761.
TTY#MassRelay Service 1-800-439-2370
MassDEP Website:WWW.mass.govldep
Printed on Recycled Paper
L ,
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I.PURPOSE
Subject to the conditions of this Approval and any other local requirements,the purpose of this Approval
is to allow installation and operation of at least 50 on-site sewage disposal systems utilizing the
technology in Massachusetts in order to conduct a performance evaluation of the capabilities of the
Technology during the first 3 years of operation of each system, in accordance with Title 5 — 310 CMR
15.286 (7),Provisional Approval of Alternative System.
The specific goal of the Performance Evaluation is to determine if the Technology is capable of
consistently meeting the concentration limits for total nitrogen (TN) of less than 11 milligrams per liter
(mg/L) for installations with design flows less than 2,000 GPD in the effluent discharged to the soil
absorption system. In areas subject to nitrogen loading limitations, increases in the discharge rate per acre
may be allowed when the nitrogen concentration discharged to the soil is reduced.
The Company is responsible for oversight and sampling of the systems during the Performance
Evaluation. The System Owner has responsibility for continued oversight and sampling of the system if
the property served was allowed to increase the discharge rate per acre above 440 gallons per day per acre
(gpda) in an area subject to Nitrogen Loading Limitations. The System Owner will be required to repair,
replace, modify or take any other action as required by the Department or the local approving authority, if
the Department or the local approving authority determines that the System is not capable of meeting the
required reduction in nitrogen in the effluent.
With the other applicable permits or approvals that may be required by Title 5, this Approval authorizes
the installation and use of the Alternative System in Massachusetts. All the provisions of Title 5,
including the General Conditions for all Alternative Systems (310 CMR 15.287), apply to the sale,
design, installation, and use of the System, except those provisions that specifically have been varied by
this Approval.
II. GENERAL DESCRIPTION OF THE TECHNOLOGY
The NitROE ® 2KS or 2KM WWTS (the `System') is installed in series between a Title-5 system septic
tank and a soil absorption system constructed in accordance with 310 CMR 15.100 — 15.279, subject to
the provisions of this Approval to accommodate design flows of less than 2,000 GPD.
The System is comprised of two-unit processes which are sequentially performed in two different
chambers. The first chamber is aerated, via an external air pump and airline header/hose arrangement,to
achieve both organic carbon reduction along with the biological conversion of ammonia-N to nitrate-N.
From the Aeration Chamber, the wastewater then gravity flows into a Denitrification Chamber where, in
the presence of natural organics from wood chips, bacteria mediate the conversion of nitrate-N to inert N
gas that exits to the atmosphere via the Title 5 system vent piping. Depending on design flow and
availability of local tank structures, the sequential Aeration and. Denitrification process steps can be
performed in the same single tank, which is NitROE® 2KS WWTS, or each process could be performed
in its own separate tank with the overall NitROE® WWTS comprised of multiple tank combinations,
which is NitROE®2KM WWTS.
The use of the Technology under this Approval requires:
• Disclosure Notice in the Deed to the property;
• Certifications by the Company,the Designer, and the Installer;
• System Owner Acknowledgement of Responsibilities;
KleanTu NitROE 2K Provisional Approval,May 2020 Page 3 of 15
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• A certified operator under contract for periodic inspection and maintenance;
• Periodic sampling;
• Recordkeeping and reporting; and
• An external power supply
III.CONDITIONS OF APPROVAL
A. Basis for Conditions
I. The term "System" refers to the Technology in combination with any other components of an
on-site treatment and disposal system that may be required to serve a Facility in accordance
with 310 CMR 15.000.
2. The term "Approval"includes the Special Conditions, Standard Conditions, General Conditions
of 310 CMR 15.287, and the approved Attachments.
3. Items required by this Approval include:
a) Performance Evaluation Plan (PEP) with sampling and analysis requirements and
approved by the Department. The PEP must be submitted to the Department for review
and approval within 60 days of issuance of this Approval and meet the requirements of
the Department's Guidance for the Preparation of Performance Evaluation Plans
<2,000 GPD;
b) Minimum System installation requirements;
c) Company schematic drawings and specifications;
d) Owner's Manual, including information on substances that should not be discharged to
the System;
e) Operation and Maintenance manual, including but not limited to, operator qualification _
requirements, inspection requirements, sampling and analysis requirements,
recordkeeping requirements, and/or reporting requirements; and
f) MassDEP Operation and Maintenance (O&M) checklist and I/A technology inspection
checklist.
B. Special Conditions
1. Department review and approval of the System design and installation is not required unless
P PP Y g
the Department determines on a case-by-case basis pursuant to its authority at 310 CMR
15.003(2)(e)that the proposed System requires Department review and approval.
2. System installations must meet the specific siting conditions for Provisional Use provided in
310 CMR 15.286(4) and the facility must meet the siting requirements of this Approval.
3. Any System for which a complete Disposal System Construction Permit Application is
submitted while this Approval is in effect, may be permitted, installed, and used in accordance
with this Approval unless the Department,the local approval authority, or a court requires the
System to be modified or removed or requires discharges to the System to cease.
4. The System Owner shall provide access to the site for purposes of sampling the System in
accordance with the Company's technology Performance Evaluation Plan approved by the
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Department, in addition to providing access for performing inspections, maintenance, repairs,
and responding to alarm events.
5. The System Owner shall ensure that no permanent buildings or structures other than the
Y p g
System, are constructed in the area for the installation of all the components of a fully
conforming Title 5 system with a reserve area. The area for a fully conforming Title 5 system
with a reserve area shall not otherwise be disturbed by the System Owner in any manner that
will render it unusable for future installation of a fully conforming Title 5 system.
6. The Department has not determined that the performance of the System will provide a level of
protection to public health and safety and the environment that is at least equivalent to that of a
sanitary sewer system.
If it is feasible to connect a new or existing facility to the sewer, the Designer shall not
propose an Alternative System to serve the facility and the facility Owner shall not install or
use an Alternative System.
When a sanitary sewer connection becomes feasible after an Alternative System has been
installed,the System Owner shall connect the facility served by the System to the sewer within
60 days of such feasibility and the System shall be abandoned in compliance with 310 CMR
15.354, unless a later time is allowed in writing by the Department or the Local Approving
Authority.
-7. The control panel including alarms shall be mounted in a location accessible to the System
Operator.
8. For any System that does not flow by gravity to the SAS, the System shall be equipped with
sensors and high-level alarms to protect against high water due to pump failure, pump control
failure, loss of power, or system freeze up. The control panel including alarms and controls
shall be mounted in a location always accessible to the operator (or service contractor).
Emergency storage capacity for wastewater above the high level alarm shall be provided equal
to the daily design flow of the System and the storage capacity shall include an additional
allowance for the volume of all drainage which may flow back into the System when pumping
has ceased.
Instead of providing emergency 24-hour storage, an independent standby power source may be
provided for operation during an interruption in power. With any interruption of the power
supply the source must be capable of automatically activating in addition to manual start up
capability. The standby power must be sufficient to handle peak flows for at least 24 hours and
sufficient to meet all power needs of the System including, but not limited to, pumping,
ventilation, and controls. Standby power installations must be inspected and exercised at least
annually and all automatic and manual start up controls must be tested. Standby power
installations must comply with all applicable state and local code requirements. Provided that a
standby power installation complies with these requirements, no variance is required to the
provisions of 310 CMR 15.231(2).
9. System unit malfunction and high water alarms shall be connected to circuits separate from the
circuits to the operating equipment and pumps.
10. All System control units,valve boxes, conveyance lines and other System appurtenances shall
be designed and installed to prevent freezing per the Company's recommendations.
I
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11. Any System structures with exterior piping connections located within 12 inches or below the
Estimated Seasonal High Groundwater elevation shall have the connections made watertight
with neoprene seals or equivalent.
12. In compliance with 310 CMR 15.240(13), a minimum of one (1) inspection port shall be
provided within the SAS consisting of a perforated four inch pipe placed vertically down into
the stone to the naturally occurring soil or sand fill below the stone. The pipe shall be capped
with a screw type cap and accessible to within three inches of finish grade.
Operation and Maintenance
13. Inspection, operation and maintenance (O & M), sampling, and field testing of the System
required by this Approval shall be performed by a System Operator with the following
qualifications:
a) is an approved System Inspector in accordance with 310 CMR 15.340;
b) has been trained by the Company and whose name appears on the Company's current
list of qualified operators; and
c) has been certified at a minimum of Grade Level IV (four) by the Board of
Registration of Operators of Wastewater Treatment Facilities, in accordance with
Massachusetts regulations 257 CMR 2.00. The name of the Operator shall be
included in the O&M agreement required by paragraph B (14).
14. Prior to the use of the System, the System Owner shall enter into an O&M Agreement with a
qualified contractor and submit the Agreement to the Approving Authority and the Company.
The Agreement shall be at least for one year and include the following provisions:
a) The name of the qualified Operator that appears on the Company's current list of Service
Contractors;
b) The System Operator must have the qualifications specified in paragraph B (13);
c) The System Operator must inspect the System in accordance with the Approval and
anytime there is an equipment failure, System failure, or other alarm event;
d) In the case of a System failure, an equipment failure, alarm event, components not
functioning as designed or in accordance with the Company specifications, or violations of
the Approval, procedures and responsibilities of the Operator and System Owner shall be
clearly defined for corrective measures to be,taken immediately. The System Operator
shall agree to provide written notification within five days describing corrective measures
taken to the System Owner,the Company, and the local board of health;
e) The System Operator shall determine the cause of total nitrogen effluent limit violations if
they occur and take corrective actions in accordance with the approved O & M Manual;
and
f) Procedures and responsibilities for recording quarterly or monthly wastewater flows must
be defined, see paragraph B (32)"Flow Metering".
15. At all times, the System Owner shall maintain an O&M Agreement that meets the
requirements of paragraph B (20).
16. The System Owner and the System Operator shall properly operate and maintain the system in
accordance with this Approval, the Designer's operation and maintenance requirements, and
the requirements of the local approving authority.
I
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17. Upon determining that the System has failed, as defined in 310 CMR 15.303, the System
Operator shall notify the System Owner immediately.
18. Upon determining that the System has failed, as defined in 310 CMR 15.303, the System
Owner and the System Operator shall be responsible for the notification of the local approving
authority within 24 hours of such determination.
19. In the case of a System failure, an equipment failure, alarm event, components not functioning
as designed or in accordance with the Company specifications, or any violations of the
Approval, the System Owner and the System Operator shall be responsible for the written
notification of the local approving authority and the Company within five days describing
corrective measures taken.
20. Within 60 days of any site visit, the System Operator shall submit an O&M report and
inspection checklist to the System Owner and the Company. The O&M report and inspection
checklist shall include, at a minimum:
a) for a System failing,any corrective actions taken;
b) wastewater analyses, wastewater flow data, and field testing results;
c) any violations of the Approval;
d) any determinations that the System or its components are not functioning as designed or
in accordance with the Company specifications; and
e) any other corrective actions taken or recommended.
21. By September 30th of each year, the System Owner and the Service Contractor shall be
responsible for submitting to the local approving authority all monitoring results with all
O&M reports and inspection checklists completed by the System Operator during the previous
12 months.
22. By September 30th of each year, the Service Contractor shall be responsible for submitting to
the Company copies of all O&M reports including alarm event responses, all monitoring
results, violations of the Approval, inspection checklists completed by the Service Contractor,
notifications of system failures,and reports of equipment replacements with reasons during the
previous 12 months.
23. A copy of the wastewater analyses, wastewater flow data, field testing results, and System
Operator O&M reports and inspection checklists shall be maintained by the Company. It is
recommended the System Owner also maintain copies of these items.
24. The System Owner shall notify the Approving Authority in writing within seven days of any
cancellation,expiration or other change in the terms and/or conditions of the O&M Agreement
required by Paragraph B(14).
25. The System Owner and the Service Contractor shall maintain copies of the Service
Contractor's O&M reports, inspection checklists, and all reports and notifications to the LAA
for a minimum of five years.
26. The System may only be installed to serve facilities where a fully conforming Title 5 system
with a reserve area exists on-site or could be built on-site in compliance with the design
standards for new construction of 310 CMR 15.000, and for which a site evaluation in
KleanTu NitROE 2K Provisional Approval,May 2020 Page 7 of 15
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compliance with 310 CMR 15.000 has been approved by the Approving Authority. A fully
conforming Title 5 system may include other approved alternative technologies in accordance
with the conditions imposed on the alternative technologies.
27. Subject to the provisions of this Approval, the Technology shall be installed in a manner
which neither intrudes on, replaces a component of, or adversely affects the operation of all
other components of the System designed and constructed in accordance with the standards for
new construction of 310 CMR 15.200- 15.279.
Effluent Limit and Monitoring Requirements,
28. For the new construction, unless the facility meets a TN effluent limit of I I mg/1 or less, the
system shall not be designed to receive more than 440 gallons of design flow per day per acre
(gpda) in an area that is subject to the Nitrogen Loading Limitations of 310 CMR 15.214. If
the facility does not meet with the Nitrogen Loading Limitations pursuant to the aggregation
provisions of 310 CMR 15.216, the System Owner shall repair, replace, modify or take any
other action as required by the Department or the local approving authority to meet the total
nitrogen concentration limits in the effluent.
Violation of the TN concentration in the System effluent shall not require notifications as
required in paragraphs B (18) and(19).
29. Prior to Department approval of the Company's Performance Evaluation Plan, the Company
shall be responsible for the following monitoring requirements for all System installations that
are subject to a total nitrogen concentration limit in accordance with paragraph B (28).
Sampling shall include pH, BOD5, TSS and Total Nitrogen, unless otherwise stated. Flow
shall be recorded at each inspection, see"Flow Metering" section below.
a) Year-round facilities shall be inspected and effluent sampled quarterly;
b) Seasonal properties shall be inspected and effluent sampled a minimum of twice per year,
with at least one annual sample taken 30 to 60 days after seasonal occupancy and a second
sample taken no less than 2 months after the first sample; and
c) After 12 rounds of monitoring, sampling may be reduced to TN only quarterly. Reduced
sampling shall also include Field Testing of System wastewater when determined
necessary by the operator, see DEP Field Testing Protocol at
http:%/www.mass.t>ov%eea/doe,s;delLI vater/laws/i-thru-z/testsamp.ndf.
Properties occupied at least 6 months per year are considered year-round properties.
Properties occupied less than 6 months per year are considered seasonal properties.
30. During the Performance Evaluation period, the Company shall follow the monitoring
requirements specified in the Performance Evaluation Plan for installed Systems.
31. After the three (3) year Performance Evaluation period by the Company and approval by the
Department, and until this Approval is modified, terminated, or superseded by a General Use
Certification, the System Owner shall comply with the following monitoring requirements if
the System is subject to a total nitrogen concentration limit in accordance with paragraph B?
(28).
1
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a) Year-round properties shall be inspected and sampled for at least the TN parameter a
minimum of twice/year, at least 5 months apart and with at least one sample taken
between December 1 and March 1 of each year. Field testing shall be completed as
determined necessary by the System operator,see DEP Field Testing Protocol at
N112•//wivw.mass.gov/eea/docs/dep/water/laws/i-thru-zftestsamn.pdf.'
Water meter readings shall be recorded at each inspection, see"Flow Metering"below.
b) Seasonal properties shall be sampled for at least the TN parameter a minimum of
twice/year. At least one annual sample must be taken 30 to 60 days after each seasonal
occupancy. A second sample must be taken no less than 2 months after the first sample.
Field testing of the System shall be completed as determined necessary by the operator.
Water meter readings shall be recorded at each inspection, see"Flow Metering"below.
32. Flow Metering - At a minimum, for all systems installed prior to this Approval, water meter
flow data shall be recorded each time the system is inspected and sampled by the System
Operator. For systems installed after the effective date of this Approval, wastewater flow data
shall be recorded each time the system is inspected and sampled by the System Operator and
may be based on:
a) actual metering data of wastewater flow to the system; or
b) water meter data for the total facility with metered non-wastewater flows, if available,
subtracted from the total facility water usage.
33. Field Testing: Turbidity, pH and Apparent Color - Turbidity, pH, DO and apparent color shall
be measured and/or recorded in the field when when determined necessary by the operator.
See applicable sections of the Department's Field Testing Protocol at
http://www.mass.gov/eea/docs/dephvater/laws/i-thr-u-z/esisam p.12
34. At a minimum,the System Operator shall inspect the System:
a) two times per year;
b) in accordance with the approved O&M manual, the Designer's operation and maintenance
requirements, and the requirements of the local approving authority; and
c) any time there is an alarm event, equipment failure, or system failure
35. The System Operator shall collect samples and obtain analysis results from an approved lab,
perform field testing required by the Approval and submit results within 60 days of the site
visit to the System Owner.
36. If the Company successfully demonstrates the effectiveness of the System to reduce nitrogen
loadings during the Performance Evaluation period, a minimum of three years, the System
Owner shall operate the System subject to the requirements of the General Use Certification, if
issued, for this technology.
C. Special Conditions Specific to the Company
1. The Approval shall only apply to model units with the same model designations specified in
this approval and meet the same specifications, operating requirements, and plans, as
provided by the manufacturer at the time of the application. Any proposed modifications of
the units shall be subject to the review of the Department for coverage under the Approval.
r
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2. Prior to submission of an application for a DSCP, the Company shall provide to the Designer
and the System Owner:
a) All design and installation specifications and requirements;
b) An operation and maintenance manual, including:
i) an inspection checklist;
ii) recommended inspection and maintenance schedule;
iii)monitoring(i.e. water use and power consumption)and sampling procedures, if any;
iv)alarm response procedures, if any, and troubleshooting procedures;
cAn owner's manual, including pro
per er system use and alarm response procedures, if any;
d) Estimates of the Owner's costs associated with System operation including, when
applicable: power consumption, maintenance, sampling, recordkeeping, reporting, and
equipment replacement;
e) A copy of the Company's warranty; and
f) Lists of Designers, Installers, and Service Contractors.
3. The Company shall implement the Performance Evaluation Plan, as submitted and approved
by the Department, and shall be responsible for all data collection and submissions to the
Department until a final determination on the Performance Evaluation has been made by the
Department.
4. Until a final determination has been made by the Department on a completed Performance
Evaluation, the Company shall submit to the Department an annual report by February 15th
of each year that includes the following:
a) a table of all sample data collected for all systems installed to date and all information
required by the Department as part of the approved Performance Evaluation Plan;
b) status of preparation of a Performance Evaluation Plan if not yet provided to MassDEP, or
any recommended changes to the approved Performance Evaluation Plan;
c) a list of pending applications for system installations which have been submitted to local
approving authorities;
d) identification of any System after start-up in violation of the Approval or not in
compliance with any performance criteria at the time of the annual report, the reasons for
the noncompliance and the status of any corrective actions that are needed; and
e) any recommendations and requests for changes to the system monitoring and reporting
plan or the performance criteria of the Approval.
The report shall be signed by a corporate officer,general partner or the Company
owner.
(Service Contractor records submitted to the Company should not be included with the
annual report to the Department,but shall be made available to the Department within
30 days of a request by the Department.)
5. The Company shall institute and maintain a program of Installer training and continuing
education that is at least offered annually. The Company shall maintain and annually update,
and make available the list of qualified Installers by February 15th of each year. The
Company shall certify that the Installers on the list have taken the training and passed the
Company's training qualifications.
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6. The Company shall institute and maintain a program of Designer training and continuing
education, as approved by the Department. The Company shall maintain and annually update,
and make available the list of qualified Designers by February 15th of each year. The
Company shall certify that the Designers on the list have taken the training and passed the
Company's training qualifications.
7. The Company shall institute and maintain a program of Operator training and continuing
education, as approved by the Department. The Company shall maintain and annually update,
and make available the list of qualified Operators by February 15th of each year. The
Company shall certify that the Operators on the list have taken the training and passed the
Company's training qualifications.
8. The Company shall not sell the Technology to an Installer unless the Installer is trained to
install the System by the Company.
9. Prior to its sale of any System that may be used in Massachusetts, the Company shall provide
the purchaser with a copy of the Approval with the System design, installation, O&M, and
Owner's manuals. In any contract for distribution or sale of the System, the Company shall
require the distributor or seller to provide the purchaser of a System for use in Massachusetts
with copies of these documents,prior to any sale of the System.
10. Within 60 days of issuance by the Department of a revised Approval, the Company shall
provide written notification of changes to the Approval to all Service Contractors servicing
existing installations of the Technology and all distributors and resellers of the Technology.
11. The Company shall provide written notification to the Department's Director of the
Wastewater Management Program at least 30 days in advance of the proposed transfer of
ownership of the Technology for which the Approval is issued. Said notification shall include
the name and address of the proposed owner containing a specific date of transfer of
ownership,responsibility, coverage and liability between them.
12. The Approval shall be binding on the Company and its officers, employees, agents,
contractors, successors, and assigns, including but not limited to dealers, distributors, and
resellers. Violation of the terms and conditions of the Approval by any of the foregoing
persons or entities, respectively, shall constitute violation of the Approval by the Company
unless the Department determines otherwise.
IV. CERTIFICATION AND NOTIFICATION REQUIREMENTS
1. Thirty (30) days prior to submitting an application for a DSCP, the Company or its
representative shall provide to the Approving Authority a certification, signed by the owner
of record for the property to be served by the unit, stating that the property owner:
a) has been provided a copy of the Provisional Use Approval and all attachments and
agrees to comply with all terms and conditions;
b) has been informed of all the owner's costs associated with the operation including power
consumption, maintenance, sampling, recordkeeping, reporting, and equipment
replacement;
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c) understands the requirement for a contract with a company approved operator and has
been provided a current list of all approved operators;
d) agrees to fulfill his responsibilities to provide a Deed Notice as required by 310 CMR
15.287(10)and the Approval; and
e) agrees to fulfill his responsibilities to'provide written notification of the Approval
conditions to any new owner, as required by 310 CMR 15.287(5).
2. Upon submission of an application for a DSCP to the Approving Authority, the Company
shall submit to the Approving Authority, with a copy to the Designer and the System Owner,
a certification by the Company or its authorized agent that the design conforms to this
Approval and that the proposed use of the System is consistent with the unit's capabilities and
all Company requirements. The review shall include evaluation of the need for installation of
water meter(s) at each facility. An authorized agent of the Company responsible for the
design review shall have received technical training in the Company's products.
3. The System Designer shall be a Massachusetts Registered Professional Engineer, or a
Massachusetts Registered Sanitarian provided that such Sanitarian shall not design a system
with a discharge greater than 2,000 gallons per day.
4. Thirty (30) days prior to delivery of the treatment unit to the site for installation, the
Company shall provide to the Approving Authority a copy of a signed contract for a
minimum period of one year with a Company approved Operator and the initial
Owner/Occupant of the property.
5. Prior to the commencement of construction,the System Installer must certify in writing to the
Designer and the System Owner that (s)he has taken the Company's training, passed the
Company's training qualifications, and is listed on the Company's list of Installers.
6. Prior to the issuance of a Certificate of Compliance by the Approving Authority:
a) In accordance with 310 CMR 15.021(3), the System Installer and Designer must certify
in writing that the System has been constructed in compliance with 310.CMR 15.000,the
approved design plans, and all local requirements, including any local approving
authority P q site-specific requirements;
b) In accordance with 310 CMR 15.021(3), the Designer must certify in writing that any
changes to the design plans have been reflected on as-built plans which have been
submitted to the Approving Authority by the Designer;
c) As a condition of this Approval, the System Installer and Designer must certify to the
Approving Authority in writing that the System has been constructed in compliance with
the terms of this Approval;
d) An authorized agent of the Company must certify to the Approving Authority in writing
that the installation was done by a qualified Installer approved by the Company and the
installation conforms to this Approval. The authorized agent of the Company responsible
for the inspection of the installation shall have received technical training in the
Company's products; and
e) Prior to signing any agreement to transfer any or all interest in the property served by the
system, or any portion of the property,.including any possessory interest, the System
Owner shall provide written notice, as required by 310 CMR 15.287(5) of all conditions
contained in the Approval to the transferee(s). Any and all instruments of transfer and
any leases or rental agreements shall be included as an exhibit attached thereto and made
f
KleanTu NitROE 2K Provisional Approval,May,2020 Page 12 of 15
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a part thereof of a copy of the Approval for the System. The System Owner shall send a
copy of such written notification(s) to the Local Approving Authority within 10 days of
such notice to the transferee(s).
V. STANDARD CONDITIONS
1. The provisions of 310 CMR 15.000 are applicable to the design, installation, use and
operation of a System utilizing an approved or certified alternative technology, except those
provisions that specifically have been varied by the conditions of this Approval.
2. The design, installation, and use of the System must conform to the terms and conditions of
the Approval and the Department approved attachments.
3. The facility served by the System and the System itself shall be open to inspection and
sampling b the Department and the local approving authority at all reasonable times.
P g Y P PP g Y
Standard Conditions Applicable to the System Owner.
4. This Approval shall be binding on the System Owner and on its agents, contractors
PP g Y
successors, and assigns. Violation of the terms and conditions of this Approval by any of the
foregoing persons or entities, respectively, shall constitute violation of this Approval by the
System Owner unless the Department determines otherwise.
5. The System Owner shall obtain all necessary permits and approvals required by 310 CMR
15.000 prior to the installation and use of the System in Massachusetts.
6. The System is approved for the treatment and disposal of sanitary sewage only. The System
Owner shall not introduce any wastes that are not sanitary sewage into the System. The
System Owner shall dispose of wastes generated or used at the facility that are not sanitary
sewage by other lawful means.
7. Prior to issuance of the Certificate of Compliance and after recording and/or registering the
Deed Notice required by 310 CMR15.287(10), the System Owner shall submit the following
to the Local Approving Authority: (i)a certified Registry copy of the Notice bearing the book
and page/or document number; and (ii) if the property is unregistered land, a Registry copy of
the System Owner's deed to the property, bearing a marginal reference on the System
Owner's deed to the property. The Notice to be recorded shall be in the form of the Notice
provided by the Department.
8. The System Owner shall at all times have the installed System properly operated and
maintained in accordance with the most recent O&M provisions of this Approval for the
alternative technology and in accordance with any additional requirements of the Approving
Authority. The most recent O&M provisions of this Approval for the alternative technology
are available from the Department.
9. The System Owner shall furnish the Department any information that the Department
requests regarding the System,within 21 days of the date of receipt of that request.
Standard Conditions Applicable to the Designer
f
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10. The Designer shall be a Massachusetts Registered Professional Engineer or a Massachusetts
Registered Sanitarian, including when designing systems for repair, provided that such
Sanitarian shall not design a system to discharge more than 2,000 gallons per day.
11. Prior to the application for a DSCP,the Designer shall provide the System Owner with a copy
of this Approval.
Standard Conditions Applicable to the Company
12. This Approval shall be binding on the Company and its officers, employees, agents,
contractors, successors, and assigns. Violation of the terms and conditions of this Approval .
by any of the foregoing persons or entities, respectively, shall constitute violation of this
Approval by the Company unless the Department determines otherwise.
13. The Company shall include copies of the Approval with each System that is sold. In any
contract executed by the Company for distribution or re-sale of the System, the Company
shall require all vendors, distributors, and resellers to provide each purchaser of the System
with copies of the Approval.
14. The Company shall make available in printed and electronic format, the approved
p Y P pp
Attachments and any approved updates associated with the Approval, to the System Owners,
Operators, Designers, Installers,vendors, resellers,and distributors of the System.
15. The Company shall submit to the Department for approval an proposed updates or changes
p Y p Pp Y p p p g
to the Attachments to the Approval.
16. The Company shall notify all System Owners, resellers, and distributors of changes to the
Approval within 60 days of issuance by the Department.
17. The Company shall notify the Department's Director of the Wastewater Management
Program at least 30 days in advance of the proposed transfer of ownership of the Technology
for which the Approval is issued. Said notification shall include the name and address of the
proposed owner containing a specific date of transfer of ownership, responsibility, coverage
and liability between them. All provisions of the Approval applicable to the Company shall
be applicable to successors and assigns of the Company, unless the Department determines
otherwise.
18. The Company shall furnish the Department any information that the Department requests
regarding the Technology within 21 days of the date of receipt of that request.
19. If the Company wishes to continue the Approval after its expiration date, the Company shall
apply for and obtain a renewal of the Approval. The Company shall submit a renewal
application at least 180 days before the expiration date of the Approval, unless written
permission for a later date has been granted in writing by the Department. Upon receipt of a
timely and complete renewal application, the Approval shall continue in force until the
Department has acted on the renewal application.
Reporting
I
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20. All notices and documents required to be submitted to the Department by the Approvalshall
be submitted to:
Director
Wastewater Management Program
Department of Environmental Protection
One Winter Street- 5th floor
Boston,Massachusetts 02108
Rights of the Department
21. The Department may suspend, modify or revoke the Approval for cause, including, but not
limited to, noncompliance with the terms of the Approval, non-payment of any annual
compliance assurance fee, for obtaining the Approval by misrepresentation or failure to
disclose fully all relevant facts or any change in or discovery of conditions that would
constitute grounds for discontinuance of the Approval, or as necessary for the protection of
public health, safety, welfare, or the environment, and as authorized by applicable law. The
Department reserves its rights to take any enforcement action authorized by law with respect
to the Approval and/or a System utilizing the Technology against the Company,the Designer,
the System Owner,the Installer,and/or the Operator of the System.
VI. GENERAL CONDITIONS
Title 5 Regulations 310 CMR 15.287: "General Conditions for Use of Alternative Systems Pursuant to
310 CMR 15.284 through 15.286"
"The following conditions shall apply to all uses of alternative systems pursuant to 310 CMR 15.284
through 15.286:
1. All plans and specifications shall be designed in accordance with 310 CMR 15.220.
2. Any required operation and maintenance, monitoring and testing plans shall be submitted to
the Department and approved prior to initiation of the use. Monitoring and sampling shall be
performed in accordance with a Department approved plan. Sample analysis shall be
conducted by an independent U.S.EPA or Commonwealth of Massachusetts approved testing
laboratory, or an approved independent university laboratory, unless otherwise provided in
the Department's written approval. It shall be a violation of 310 CMR 15.000 to omit from a
report or falsify any data collected pursuant to an approved testing plan.
3. The facility served by the alternative system and the system itself shall be open to inspection
and sampling by the Department and the Local Approving Authority at all reasonable times.
4. The Department and/or the Local Approving Authority may require the owner or operator of
the system to cease operation of the system and/or to take any other action necessary to
protect public health, safety,welfare and the environment.
5. The owner or operator shall provide written notice to any new owner or operator that the
system is an alternative system. Such notice shall include notice of the general conditions and
any special conditions applicable to the system and its owner.
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6. The owner or operator, or the proponent of the alternative system, shall obtain and provide
the Department with a determination from the board of certification of operators of
wastewater treatment facilities established pursuant to M.G.L. c. 21, § 34A as to whether a
certified operator is required for operation of the alternative system. The Department shall
waive this requirement if it has on file a determination for the alternative system, and shall
notify the owner, operator,or proponent of the determination.
7. It is a violation of 310 CMR 15.000 to install, construct, or operate an alternative system
except in full compliance with the written approval and 310 CMR 15.287.
8. The Department may require the issuance of a groundwater discharge permit pursuant to 314
CMR 5.00 (groundwater discharge program)for any alternative system.
9. The system owner shall maintain an operation and maintenance contract with a
Massachusetts certified operator where one is required by 257 CMR 2.00, or otherwise with a
person qualified to operate and maintain the system in accordance with the Department's
written approval.
10. Prior to obtaining a Certificate of Compliance for installation of a new or upgraded system,
the system owner shall record in the chain of title for the property served by the alternative
system in the Registry of Deeds or Land Registration Office, as applicable, a Notice
disclosing both the existence of the alternative on-site system and the Department's approval
of the system. The system owner shall also provide evidence of such recording to the Local
Approving Authority.
939 main street rte.6a - tel.(508)362-4541
yarmouth port
mass 02675 fax(508)362-9880
down cape engineering, inc
Daniel A.Ojala,P.E.,P.L.S.
land court civil engineers&land surveyors
surveys Arne H.Ojala,P.E.,P.L.S.
Daniel E.Gonsalves,P.E.,S.E.
Craig J.Ferrari,E.I.T., S.E.
structural design
site planning September 10, 2021
sewage designs system Barnstable Board of Health,- Septic Upgrade,MacKinnon,33 Oyster Place Rd, Cotuit
inspections bear Abutter:
permits A public hearing has been scheduled for the Barnstable Board of Health to act on a
request to approve variances from the Town of Barnstable Regulations for the
proposed Title 5 septic system upgrade at 33 Oyster Place Rd, Cotuit. A NitROE
nitrogen reducing system is proposed.
Title 5 (310 CMR)Variances Requested:
15.213 (1)Installation of a septic tank in a velocity zone
15.405 (1f)Reduction in setback, septic tank to coastal bank(25'to 0')
15.405 (If)Reduction in setback, septic tank to coastal bank(25'to 0')
15.405 (1 a)Reduction in setback, septic tank to coastal bank(25'to 0')
Barnstable Health Regulations(VIII):
Reduction in setback, SAS to Coastal Bank(100' to 0')& septic tank to
coastal bank(100' to 0')
Said hearing will be held in person at 3:00 PM on September 28, 2021, in the James H.
Crocker Jr. Hearing Room, 2nd Floor, Barnstable Town Hall, 367 Main Street,
Hyannis, MA. It is recommended to check the Town of Barnstable website for the
official agenda to confirm date and time if you are interested in attending the meeting.,
Plans and the application describing the proposed activity are on file at the Barnstable
Board of Health office, 508-862-4644.
Sincerely,
o c�. e
J
Daniel A. Ojala, PE, PLS
Down Cape Engineering, Inc.
Board of Health Title V Septic Variance Abutter List for Subject Parcel 035101
Direct abutters(no set distance)and the properties located across the street.
Parcel ID Owner i Owner 2 Address Line Y Address Line 2 City State Zip
035085 PIKE,CHRISTOPHER C&LINDSAY J 66 BEAUMONT AVENUE NEWTONVILLE MA 0246o
035089 BARNSTABLE,TOWN OF(LDG) 367 MAIN STREET HYANNIS MA o26oi
035090 MACKINNON,DONALD J TR %MACKINNON,MATTHEW J TR PO BOX 152 HINGHAM MA 02043
035101 MACKINNON,MATTHEW J TR %MACKINNON,DONALD J TR PO BOX 152 HINGHAM MA 02043
Page i of 1 Total Number of Abutters:4 Report Generated On: 9/10/2021 10:17 AM
This list by itself does NOT constitute a"Certified List of Abutters"and is provided only as an aid to the determination of abutters. If a Certified Abutter List is required,you must contact the Assessing Division to
have this list certified.
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ARCF0IECTURAL IMIOVA7IClNS
PROPOSED SECOND FLOOR PLAN ADWRWW a'm"m'a
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No...__....1-! ':_.. Fxs.. E ....................
THE COMMONWEALTH OF MASSACHUSETTS
L
BOARD OF HEALTH
... .............O F..............................................,.......I..............................---
. pVhrntiun -fur 15hipuiittl Workii Tonstrnrtinn Permit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
r
Location•Addmss / or Lot No.
W Owner Address
Installer Address
Q Type of Building Size Lot___________________________Sq. feet.
Dwelling �--- _---_--Expansion Attic ( ) Garbage Grinder ( a
of Bedrooms. ..................•-- —P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( )
d.< Other fixtures --------------------------------------------------------------------_----------
W Design Flow_ .._____ .............................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—4—rlquid capacity/l,_-�t_)_(j_gallons Length................ Width................ Diameter---------------- Depth-------------
i
x Disposal Trench-�No. .................... Width_,:?........___ - ,_ Total Length._ .. _._.. Total leaching areal �_-----sq. ft.
Seepage .Pit No_____________________ Diameter.................... Depth below inlet------------ _. Total leaching area-----------------_sq. ft.
z Other Distribution box ( ) Dosing tank ( ) d.b.a e/ — — �'— 7(.
aPercolation Test Results Performed by---- N: z ---------------------------------------- Date........le'.A --.---__-__--
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...----.-------.--.--._
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-.- .---__-.__,--------
a -------------------------
O Descriptign of Soil - �^ 3�
.
-----------
------------
x ---------------��- N=L � �
U Nature of Repairs or Alterations—Answer when applicable_____________ _
� , 2
. .. ..... ......... . . .. �/ ------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig ed__. . er .,; �: (,�i.1 °L2 ` �< —�•6
t
Application Approved By 7 --------------
4 - LA�-�� Date
Application Disapproved for the following reasons:.............................`---------•-------------------•-•-----------------.------------•-------•-----------
............................•---••-•---•--....----------------•-•---•-....-•---------------•--------•-------------------•-------------------------------••-------------•-•--•------------------- ------
Date
PermitNo......................................................... Issued........................................................
Date
Ax
70 .�
No..-•-.••..�1�'• Fes$... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_...-- ..OF...................................................................... .....-----------
Appliratiutt -fur UiB uutt1 Worko Tomitrttrtiutt Vaniit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: )
Location-Address i/ or Lot No.
........ -- _�_... -U � .•......... .. .--------------------------------------------------------------------------
Owner Address
Q Type of Building - Expansion Attic Size Lot•-Garba e Grinder feet D
Installer Address i
Dwelling�. of Bedrooms._..._...._''"L_____ p ( ) g (
aOther—Type of Building -__-._.._________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------- -------------- --
--------------------------------------------------------------------------------------------
W Design Flow________. <-0 ---------------------------------------------------------------------------------------------
per person per clay. Total daily flow.... .0...4------------------------gallons.
WSeptic Tank quid capacity -ogallons Length................ Width--------------- Diameter__._...-__.-.-_ Depth----------------
x Disposal Trench-2--No_ ____________________ Width__ --------- Total Length_.-,J`�-.S. ...._. Total leaching area.. w......sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet____ ______ _-_. T taI leaching area-------_.._:-----sq. ft.
Z Percolation Test Results ) Performed b .__ga`f�. )_tPi_..1 ......................C..__......__ Date------- -__ --__7- ---.-------.
Other Distribution box Dosing tank O/✓� — � - S- - 7 G,
a Y
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water.---_--.._----.-_-.-.---
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water._.--.-.._-._-_---_-__--
P4 ---•--..._•----- -- ? ---•- - ------------------------
-
G Description of Soil._______-_. __. y� ^� '» __.�. .��.. . .
1----
.----•... ---...
----- ---- -
U a- 4-- � - ��'�
----------
/ '_ C
x ------q-- ----� --------------------- �'t�. C r�n� c �
U Nature of Repairs or Alterations—Answer when applicable-----------_-------------------------------------------------------- --------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the
. board of health.
C�/ake . c�� 7 9-7 6
to
Application Approved By----- f - -------------
Date
Application Disapproved for the following reasons:................................................................................................................
.................................•------.•------------------•-•-•---------•---•-•-•-••---•----•-•-•--...... ------------------
Date
PermitNo......................................................... Issued...................... ----------......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF�HEALT......rd'44 1.................OF......... . .I........................
Tntifiratr of TIMp a urr
T j IS TO CERTIFY�hat he Individual Sewa e Dis osal S stem constructed or Re airedg P �' ( ) P by...- A`'� Installer
at =� K= ........ -------------------------------------------------------------------------------------•------------ ------
has been ifistalled in accordance with the provisions of Article XI of The State Sanitary Code as descri ed in the
application for Disposal Works Construction Permit No----------------------------------------- dated.... /��.-... .._..___........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A'S A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1� j....rf!.s ?............O F......... . .............................. .�............-•--•-....
/ GL.�
No. .............. FEE--- �J---•------•--
%spoiial Norkii Txmitrturtiutt rrrmit
Permissionis�kereby granted-------------------------------------------- ....................... ................... ......................................................
to Constr t- ) or . epair an�dividual ge Disposal S st
at No..' f�+�/ �•�+ -------- -------- .................................................
�,
Street
as shown on the application for Disposal Works Construction ermit o .._ ------- Dated-----?:__��-_.X..............
�? 141'
-G1-1.----•...................................... Board of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
... .. .l � V J �J r . .ti Fe$ 50.00
No. _ �i' G l D
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(pplication for Migogal *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( )UpgradeTXTAbandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 33 Oyster Place RD Owner's Name,Address and Tel.No. Wendy Lyons
ACO ods'lVra�lP'azac�S . 02635 Oyster Place Road Cotuit,Mass . 02635
Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—77 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerfville,Mass . 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XX No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder ITO)
Other Type of Building RF S No.of Persons 2 Showers( ) Cafeteria( )
Other Fi s
Design FI LLO gallons per day. Calculated daily flow�4x 1 1 0 gallons.
Plan Da a Number of sheets Revision Date
Tit
Size of Septic Tank Type of S.A.S. 2_nn�neh
es
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) 1 _H2.0 Pump Chambej---
t t �- t- Q
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 Environme tal Code and not to lace the system in operation until a Certifi-
cate of Compliance has been issued by t 's Boajofalt
Signed .
Date 11 /7/96
Application Approved by / Date
Application Disapproved for the following reasons
Permit No. LDate Issued
----------------------------- --------
�.. Nu --
n 035 .: .`'� Fee
:� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC.HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
~ TippYica#tion for Migaal *p6tem Con6truction Permit
Application for a Permit to Construct( )Repair( )UpgradjX�TAbandon( ) ❑Complete System ❑Individual Components
t
Location Address or Lot No., 33 Oyster Place RB Owner's Name,Address and Tel.No. Wendy Lyons
Cotu t,,Mass . 02635 Oyster. Place ,Road Cotuit,Mass .02635
Assessor's a /Parcel ,. .,.. +-
Installer's Name,Address,and Tel.No. 508-775-3338 Designer's Name,Address and Tel.No. 508-775-3335
".-J.,P.Mae,omber & Son Inc. J.P.Macomber & Son Inc.
Box 66 C enterfvlle,Mass.j, 02632 . Box 66 Centerville,Mass . 02632 .I
Type of Building\ r
Dwelling XX iNo.of Bedrooms. 2 Lot Size sq. ft. Garbage Grinder(VO)
Other Type of Building I'AES No. of Persons 2 Showers( ) Cafeteria( )
Other Fixt -es 1'
Design Flo 4440 gallons per.day. Calculated daily flow 4x1 1 0 gallons.
Plan Date Number of sheets Revision Date
Size of Septic Tank Type of S.A.S. 7._ryn
Description of Soil Sand
Nature
atu a of Repairs or Alterations(Answer when applicable) 1—H2O Pump Chambeerb.-20 _
S J'
Date last inspected: '
Y Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisiors°-of Title 5 of the Environme gal Code and not to lace the system in operation until a Certifi-
cate of Compliance has been issued by this Board of ,ealt X
Signed /r i��4�i`hYf Date 11 /7/96
46
Application Approved by �, o / Date
Application Disapproved for the following reasons,
Permit No. Date Issued 11T . Y70
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )tRepaired ( )Upgraded( X)5.
Abandoned( )by J..P.Macomber & Son Inc.
at 33 Oyster Place Road Cotuit.,Russ a en cons ct d in accordance '
with the provisions of Title 5 and the for Disposal System Construction Permit No. "` dated
I
Installer J P .MacnmhAr Pi firm T•n n. / Designer
'�oThe issua ce of this permit shall L a construed as a guarantee that the sys Fri.; i function as desi �ned.
O
a
No.
j .p -------- ---------------- 50--
-00
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS e
M.5pont 6potem Congtruction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade4X )Abandon( )
System located at 33 Oyster Place Road Cotuit.Mass .
s 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 v
Provided:Constructio: must e c mpleted within three years of the date of 76,perrmt.Date: I I I Approved by // �� _ wif
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1. M m �
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C�
' P
CERTIFICATION OF SKETCII AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PEIZIYII'T (WITI(OUT DESIGNED PLANS)
I Joseph P. Macomber Jr. 1, rrby certily that the application for disposal works
construction permit signed by nie ci;ttcd 11 /96 , concerning the
property located at 33 O tltii-t 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 A feet or greater below the bottoin of the leaching facility
• There is no increase in flow and/or ch;ngc ill use proposed
• There are no variances requested or needed.
SIGNED • __
DATE: 11 /8/96
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUN BI<R__!&4
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses.a certified plot plan,
this plan should be submitted),
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT_OF ENVIRONMENTAL.PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 33 Oyster-PlaceRoad
Cotuit, MA 02635
Owner's Name: Paul Cain
. . Owner's Address: 8695 S.E. Compass Island Way
Jupiter, FL 33458 �� ' 4uA
Date of Inspection: September 16, 2007
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49 ��l
Osterville.MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT.
I certify that.I have personally inspected the sewage disposal system at this-address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my,
training and experience in the proper function and maintenance of on site sewage disposal systems I�am a DEP
approved system inspector.pursuant to Section 15.340 of Title 5(310 CMR 1.5.000),. The:system: `
Passes
Con ' Tonally Passes {
..
Ne s Further Evaluation by the Local Approving Authority Tay_
Fai s ��
Inspector's Signature: ' Date. 8e (ember 24 200. -
The system inspector shall subs a copy thi inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of complett this inspection. If the system is a shared system or has a design flow of 1:0,000
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
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address.how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
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
B. System Conditionally Passes:
l
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)"in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over.20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or enfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or 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:
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
obstruction is removed
ND explain:
2
Page 3 of 11
r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
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 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 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
D. System Failure Criteria applicable to all systems:.
You must indicate either"yes"or"no"to each of the following:for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or,
clogged.SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth.in cesspool is less than 6"below invert or available volume is less than ''/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 well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ ✓ Any portion of a cesspool or privy is.less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
' are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E.. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310.CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS {
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
Check if the following have been done: You must indicate"yes"or"no"as to each of the following: .
Yes No
✓ _ Pumping infonnation 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?
i
✓ 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?
` i I
The size and location of the Soil Absorption System(SAS)on the site has been detenhined based on:
..Yes No
✓ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 33 Oyster Place Road
Cotuit,MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example:.110 gpd x#of bedrooms): 220
Number of current residents: 0
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] .
Laundry system inspected(yes or no): No
Seasonal use(yes or no): Yes
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No ...
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): spd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes.or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records:
Source of information:. Pumped in 2006-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: , gallons--How was quantity pumped detennined?
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)
Tight Tank Attach"a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
A leach faeld was added in 1996-per as built card
Were sewage odors detected when arriving at the site(yes or no.): No
6 -
Page 7 of 11 t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul.Cain
Date of Inspection: September 16, 2007
BUILDING SEWER(locate on.site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain_):
Distance from private water supply well or suction line:
Comments(on condition of joints;venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) R
Depth below grade: 10"
Material of construction: ✓ concrete _metal fiberglass polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance.(yes or no): (attach a copy of
certificate)
Dimensions: 1000 Qal.
Sludge depth: 2" <
Distance.from top of sludge to bottom of outlet tee or-baffle: 30"
Scum thickness: S"
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: 10"
How were dimensions determined: Measuring stick
Commments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.).
Tees were present. The inlet steel cover was to grade. There did not appear to.be-any signs of leakage.
GREASE TRAP: None (locate on site,plan)
Depth below grade:
Material of.construction: _concrete metal fiberglass,_polyethylene _other }
(explain):
Dimensions:
Scum thickness: ,
Distance from top of scum to top of outlet tee or.baffle:
Distance from bottom of scum to bottom of outlet tee or baffle`.
Date of last pumping:
Comments(on pumping reconunendations,inlet and outlet tee or,baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.)-
7
F
Page 8 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 Oyster Place Road
Cotuit. MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
There were no signs ofsolids or backup.
PUMP CHAMBER: 2 (locate on site plan)
Pumps in working order(yes or no): Yes
Alarms in working order(yes or no) Yes
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
The pump in the chcunber for the cottage was not working. A new pump was installed. The puni�for`the house was in working
order.
8
Page 9 of 11
OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: Septenzber.16, 2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 3 Cultecs w/stone(per as built)
leaching galleries,number:
✓ leaching trenches,number, length: 2-35'x 2'trenches (per as built)
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.):
Steel covers were to grade. There did not appear to be anv suns of failure.
CESSPOOLS: None (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 or no):
Comments (note condition of soil;signs of hydraulic failure,'level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of pending,condition of vegetation,etc.):
9
Page 10 of .11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33'Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
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: '
=0TrAI'L
A
3o y�
�. .`.'.
a
10
i
� 6
' Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
SITE EXAM
Slope z
Surface water
Check cellar
Shallow wells
o
Estimated depth to ground water 6'+/ feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours neaps.
Checked with local.excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours[naps the naps were showing approximately 6'+1-to ground water at this
site. The SAS is in a raised system approximately 1 S'to ground water.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees,either expressed,.written or,implied,
relating to the septic system, the inspection; this report andlor any components of the septic system which have not
been located and inspected.
1.1
{
Town of Barnstable
f 1HE
Regulatory Services
BARNSTABLE.
Thomas F. Geiler,Director
l
E��A Public Health .Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
.p
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations,
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
i
r
Commonwealth of Massachusetts
a W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road C
Property Address _T—
Paul Cain OD
Owner Owner's Na e 11•+
information is cm
required for every Cotuft MA 02635 5/26/2016 �o
page. City/Town State Zip Code Date of Inspection
W
CA
Inspection results must be submitted on this form. Inspection forms may not be altered in anym
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
# �/
on the computer, 3 ,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return Name of Inspector
key.
Ford Septic Services, LLC
!� Company Name
P.O. Box 49
Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S12482
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
`r
® Passes ❑ Conditionally Passes ❑ Fails
Needs Further v uation by the Local Approving Authority
5/31 1/ 6
InSpec r ignature Date
The s ste inspector shall submit a copy of this inspection report to the Approving Authority(Board
of ea r DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
•a
15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�o d Vs
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is required for every Cotuit MA 02635 5/26/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements, If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is.available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is required for every Cotuit MA 02635 5/26/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
r
❑ 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):
I
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is required for every Cotuit MA 02635 5/26/2016
page. Cityrrown 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:
I ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Yz day flow
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is required for every Cotuit MA 02635 , 5/26/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
1
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply. ,
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El N The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to-the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section 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.
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 33 Oyster Place Road
GM v V
Property Address
Paul Cain
Owner Owner's Name
information is
required for every COtUIt MA 02635 5/26/2016
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:
Number of bedrooms (design): 4 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/26/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: n/a
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: currently
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
r
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is
required for every COtUIt MA 02635 5/26/2016
page. CitylTown 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: unknown
Was system pumped as part of the inspection?
❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
TypeS of stem:
Y
® 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):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is required for every Cotuit MA 02635 5/26/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
a leach field was added in 1996- per as built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting,evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 10"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gal.
Sludge depth: 1
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/26/2016
page. CityrTown State Zip Code Date of Inspection
D. System Information. (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 27
Scum thickness 6
Distance from top of scum to top of outlet tee or baffle 5
Distance from bottom of scum to bottom of outlet tee or baffle 10
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of :leakage, etc.):
)
The tees were present, there were no sign of leakage. The inlet cover was to grade. recommend
pumping the tank.
Grease Trap(locate on site plan):
Depth below grade: n/a
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM a 33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is required for every Cotuit MA 02635 5/26/2016
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
N/a
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M a 33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is t
required for every Cotuit MA 02635 5/26/2016
page. CityrFown 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- even
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, an
evidence of leakage into or out of box, etc.): y
There were no signs of backup.
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.):
There were 2 pump chambers, both were working
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:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Oyster Place Road
Property Address —.
Paul Cain
Owner Owner's Name
information is COtUIt
required for every MA 02635 5/26/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3-cultecs
w/stone per info
❑ leaching galleries number:
® leaching trenches number, length: 2-35'x2'trenches
❑ 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.):g :c )
I dug down in the stone in the SAS and the stone was dry and clean. There was no sign of failure.The
SAS has a high elevation.
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
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'°M a 33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/26/2016
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.):
i
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.):
N/a
15ins•1113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
l
F
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/26/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
C AA �-
ST�t,I rS
(3
a
So
a 3o
t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�M a 33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/26/2016
page. City/Town State Zip Code Date of Inspecticn
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 6'+/-
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:
Topo and water contours map.
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
The SAS is in a raised system approximate) 15' to groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Paul Cain
Owner Owner's Name
information is
required for every COtUIt MA 02635 5/26/2016
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
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
V Vr1/P V��y J� I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
L- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
S
33 Oyster Place Road
Property Address
Michael Bass Truste r,,
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
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.
Impg out
When
fillip out forms A. Inspector Information
on the computer,
use only the tab James Ford
key to move your Name of Inspector
cursor-do not Ford Septic Services, LLC
use the return Company Name
key.
P.O. Box 49
Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S 12482
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
2. ❑ Conditionally Passes
3. ❑ Needs Furth r E luation by the Local Approving Authority
4. El Fails
5/28/2019
Inspec 's Signature Date
The s em inspe for shall submit a copy of this inspection report to the Approving Authority (Board
of Hea 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. v
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 P V
-j y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
33 Oyster Place Road
Property Address
Michael Bass Truste .
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1 2 r n I p ry p , 3, 0 5a and of4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
Y
❑ 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit . MA 02635 5/23/2019
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):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):,
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page.3 of 18
y I
Commonwealth of Massachusetts
Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
page. City(rown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the,SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l." Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. 33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
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 '/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.
❑ ® 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 at facility with at
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"ono"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
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
Title 5 Official Inspection Form
(- <� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v!% 33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 .5/23/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No ,
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is Cotuit MA 02635 5/23/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms)' 440
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
Date
I
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
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:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: uknown
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
(- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
page. Cityfrown 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:
a leach field was added in 1996 -per as built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 118
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is Cotuit MA 02635 5/23/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
' 101,
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy.of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal.
Sludge depth: 1
Distance from top of sludge to bottom of outlet tee or baffle 27
Scum thickness 2
Distance from top of scum to top of outlet tee or baffle 5
Distance from bottom of scum to bottom of outlet tee or baffle 12
How were dimensions determined? measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present. There was no sign of leakage. The cover was to grade.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑•polyethylene ❑ other(explain):
N/a
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee.or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/a
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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'w <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 33 Oyster Place Road
u�
Property Address
Michael Bass Truste
Owner Owner's Name
information is Cotuit MA 02635 5/23/2019
required for every '
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.):
N/a
*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 even
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.):
There were no sign of backup
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
i
page. Cityrrown 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.):
There is a small septicTank with a pump that serves the small outbuilding and that pumps up to the
other septic tank. There is a pump chamber that serves the house.
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type
❑ leaching pits number:
® leaching chambers number: 3-cultecs with
stone. per info '
❑ leaching galleries number: ,
® leaching trenches number, length:. 2-35'x2'trenches
❑ leaching fields number, dimensions:
❑ 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
I dug down in the stone in the SAS and the stone was dry and clean. There was no sign of failure.
The SAS is up high in elevation.
12. 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
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: N/a
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
k
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
. i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System: I
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
r
(-1 oast
Q
A ` - S re�.I COVGcs
a
0
A l3
I '
1 yq S6
a 30 YS
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,�. 33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
page. Cityrrown 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: 6 +/
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: pate
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Topo and water contours map.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The SAS is in a raised system approximately 15'to groundwater.
i
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
i
f
'c Commonwealth of Massachusetts
i F
1� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. �!% 33 Oyster Place Road
Property Address
Michael Bass Truste
Owner Owner's Name
information is required for every Cotuit MA 02635 5/23/2019
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed &Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate ;
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
j
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
h
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
,'
UWTED STATES PgTjL1rJPRVW (Mf!If:[,[I !� s !s #sltlsasta}(! First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
• Gpnder: Please print your name, address, and ZIP+4 in this box •
i
Town.of Barnstable
Health Division
C200 Main Street
Hyannis,MA r01
I
COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. X ❑Agent.
■ Print your name and address on the reverse ❑Addressee t,
so that we can return the card to you. B. Receive (Printed Named C. Date Of Uelivery
■ Attach this card to the back of the mailpiec% J/ Pp Prin, �, {�
i or on the front if space permits. l� , Y�J
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑'No
I
r
»;
i
Paul C- ain
v,1601 Heritage Drive
Suite 117 3. S ice Type
.J'piter, FL 33458-2784 ertified Mail ❑Express Mail
❑ Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
( d
(transfer from service label) k : � 7 0 0 8 3.2 3 0; 0 0 0 2 . 517;8 0 4 8 6 ;
PS Form 3811,February 2004 Domestic Return Receipt 102595702-M-1540
� r3 ��.,---�
y {�
r
FORM30 C'W HoBBsB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOAF OF HE TH
CITY/,TOWN — 7) , V ,
D ARTMENT
GSM Sye��'
ADDRESS
ELEPHONE �
Address J _ Occupan
Floor Apartment go. No. of Occupants
No. of Habitable Rooms No.Sleeping Rooms
No.dwelling or rooming units o.Stgries
Name and address of ownerJ�
Rfynarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches: C
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:-
Chimney:
BASEMENT Gen.Sanitation.-
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line: -.�
❑ MS ❑ ST ❑ P Waste Line: 91,119
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities 5
tove .
Bathing,Toilet Facil. , Plumb., anit'n.:
Wash Basin, Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n.-
General r Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
,AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION PORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES U "
INSPECTOR TITLE
aA.
DATE TIME
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health,or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation,of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns,shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire,"burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
N Failure to provide a smoke detector required b 105 CMR 410.482.
O P q Y
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
r
Town of Barnstable, Regulatory Services October 22,2012
Mr.Timothy O'Connell, Health Inspector, Public Health Division
200 Main Street
Hyannis, Ma 02601
RESPONSE TORS HEALTH INSPECTOR LETTER DATED AUGUST 20,2012—FOLLOW UP
Dear Mr. O'Connell,
Since my tenant departed at the end of last month, my caretaker of the property, Mr. Michael Mayne,
has been able to arrange for the repair of the leaking the in the upstairs shower at 33 Oyster Place Rd. in
Cotuit. His phone number is 508.737.2422 if you would like to verify.
This letter should serve you as the confirmation of the completion of the work.The sower no longer
leaks.
You have already received confirmation that I have secured and provided a countertop convection oven
large enough to cook a small turkey at the cottage.
You can contact me anytime for any additional information if needed.
Thank you. -
Paul Cain, Ph.D.
601 Heritage Dr.Ste. 117
Jupiter, FI 33458
561.254.4390
Town of Barnstable, Regulatory Services August 30, 2012 '
Mr.Timothy O'Connell, Health Inspector, Public Health Division
200 Main Street
Hyannis, Ma 02601
RESPONSE TO R.S. HEALTH INSPECTOR LETTER DATED AUGUST 20 2012
Dear Mr.O'Connell,
As per our conversation this morning, my plan to correct the violations pointed out in your letter dated
August 20, 2012 is as follows:
1) The upstairs shower(one of four showers on the property) leaks water through the the when in
use. My tenant has agreed not to use this shower in return for an 'inconvenience rebate'. Her
rental agreement expires September 301h.After her departure I plan to have the shower stall
completely re-tiled in order to correct the leak which allows water into the wall behind.
2) 1 will secure and deliver to the property a large counter-top style convection/microwave oven to
supplement the regular count-top oven and the microwave oven that are already on the „
property.This will be done in a matter of the next few days.
I will follow up with you to confirm the completion of these two tasks.
Thank you for calling these violations to my attention.
Paul Cain, Ph.D.
601 Heritage Dr. Ste. 117
Jupiter, FI 33458
561.254.4390
Town of Barnstable, Regulatory Services September 10, 2012
Mr.Timothy O'Connell, Health Inspector, Public Health Division
200 Main Street
Hyannis, Ma 02601
RESPONSE TO R.S.HEALTH INSPECTOR LETTER DATED AUGUST 20,2012—FOLLOW UP
Dear Mr.O'Connell,
Enclosed you will find a copy of my email to the tenant at 33 Oyster Place Road in Cotuit pertaining to
the delivery of a counter top convection oven as well as the purchase confirmation.
She will be moving out at the end of this month and the shower the repair will be completed before the
cottage is rented again.
I will confirm with you when that work is finished. I estimate this will be done before October 15`h.
Thank you for calling these violations to my attention.
l�
Paul Cain, Ph.D.
601 Heritage Dr. Ste. 117
Jupiter, FI 33458
561.254.4390
i
9/8/12 Gmai-Oven delivery
• � I
Gma
t"(AXNtt
Oven delivery
Paul Cain <pauPcainphd@gm ail.com> Sat, Sep 8, 2012 at 9:52 AM
To: Laura Davis <lauradruns@comcast.net>
Dear Laura,
As you know, I have been cited for two violations by the Health Department of the Town of Barnstable due.to your
report of the leak,in the upstairs shower and the absence of al oven in the cottage.
Since you have chosen to stay on in the cottage, I have communicated to the Health Department that the tile
work -which will require scheduling multiple visits to the cottage to complete-will begin after your departure at
the end of this.month. I have sent the Health Department a letter to that effect.
In regard to the oven, I have purchased and-am sending to the cottage address a new counter top oven that
meets the requirements of the Health Department in that it is a)a convection oven, and b)large enough to cook a
small turkey; these are the two criteria set by the town authorities. You can expect UPS to deliver this oven in
the next few days.
My wife and I will be arriving on the Cape at the end of the month and we will do a walk through at the cottage on
Monday, October 1. Kindly arrange the furniture back the way you found it and leave the keys on the dining table
on the 30th.
Best regards,
Paul Cain
mag®A;0Wy for Big Boss Rapid Wave Halogen Infrared Convection Coun_ertop Oven-12...
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Countertop Oven
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with Extender
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ti.,nl..a..«
Citizen Web Request Page 1 of 3
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MMS
_+ Thursday,August 16 2012
TOWN\oconnelt
Logged In As: _Citizen Request Management',
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Route to Users Search Requests Create Requests
Request Information
Y '
Request ID: 40978 Created: 8/13/2012 5:02:53 PM
Status: Assigned-To Staff Assigned To: O'Connell,Timothy
Health Office ..
Anonymous: Yes Bequest Category: Chapter II : Housing Substandard edit
Routine work: No Estimate: No ' edit
Date scheduled: edit
Estimated 8/27/20112 Change Estimated . ]uI August 2012 SSe
Completion Completion Date:
Date: Sun Mon Tue Wed Thu Fri Sat
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Created By: Crocker,Sharon Priority: Medium edit
Health Office
Citation Numbers: ' edit
Requestor Information
Requestor Request 'Aunt Tempy Condo #.1A- Bonnie Steen '
DETAILS: LOCATION: 234 PARKER ROAD'
Osterville, Ma 02655'-=
Request Parcel Number Map: 116 !Block: 061 Lot: OOA '
Parcel Lookup
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http://issgl2/intemalwrs/WRequest.aspx?ID=40978 8/16/2012
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Certified Mail#7008 3230 0002 5178 0486
Town of Barnstable
Regulatory Services
BARN STABLE,
� KAM $ Thomas F. Geiler, Director
prfD MA'S `�
a Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
August 20, 2012
Paul Cain47
601 Heritage Drive
g �
Suite 117
Jupiter, FL 33458-2784 (0 >
NOTICE TO ABATE VIOLATIONS'OF 105 CMR 410.000 STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 33 Oyster Place Road Cotuit, MA was inspected on
August 17, 2012 by Timothy O'Connell, R.S. Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of a complaint the Town of
Barnstable received.
c �
The following violations of th�St Sanitary Code were obser ed: ,I` x 9 T(� ��V-
105 CMR 410.351—Owner's Installation and Maintenance Responsibilities. Shower
located on second floor was observed to be leaking into first floor kitchen. Mold like
U
substance on kitchen ceiling was present.
105 CMR 410.100 - Kitchen Facilities. There is.not an oven provided within unit for
cooking purposes.
You are directed to correct the violations listed above within seven (7) days of your
receipt of this notice by correcting leak occurring within said shower; by repairing
ceilings so they are finished and no longer have a mold like substance; by installing
an oven within unit.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served. Non-compliance will
QAOrder Ietters\Housing violations\33 oysters place road 8-17-12
result in a fine of$100.00 per violation. Each day's failure to comply with an order shall
constitute a separate violation. Should you have any questions regarding the above
violations, please contact the Town Health Division and ask to speak with the inspector
who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. Mc an, R.S., CHO
Direefor of Public Health
Town of Barnstable
Q:\Orderletters\Housing violations\33 oysters place road 8-17-12
Sb
' COMMONWEALTH OF MASSACHUSETTS 1 /
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
G
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 3-3 Ovster Place Road �f
I Cotuit, MA 02635 _ I 1�( G
Owner's Name: Paul Cain �-1 b 1
Owner's Address: 8695 S.E. Compass Island Way
Jupiter, FL 33458
Date of Inspection: September 16, 2007
Name of Inspector: (Please Print) James M. Ford '
Company Name: James M. Ford N
Mailing.Address: P.O.Box 49to
Osterville.MA 02655-0049
Telephone Number: (508) 862-9400 = .
ca
CERTIFICATION STATEMENT c9Z
to .
I certify that I have personally inspected the sewage disposal system at this address and that the info ation r6j%rted
below is true,accurate and complete as of the time of the inspection. The inspection was performed., ased on my
training and experience in the proper function and maintenance of on site sewage disposal systems. `I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system`.
Passes
Conditionally Passes
e ds Further Evaluation by the Local Approving Authority
is
Inspector's Signature: Date: May 27, 2008
The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of.105000
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.
Report was revised for Bedroom designed,see plan#96-596 per board of health on 5/16/08
Notes and Coimnents original report dated September 24,2007
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form N15/2000 paged
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not detennined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally'
unsound, exhibits substantial infiltration or exfiltration-or tank failure is inuninent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or 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:
The system required purnping 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
obstruction is removed
ND explain: `
2
Page 3 of 11
OFFICIAL INSPECTION FOR
M -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
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 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 aseptic 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3: Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM.-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due.to an overloaded.or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z 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 I 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. [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 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to detennine what;will be necessary to correct the failure.
E. Large System:
To be considered a large system.the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
"yes"to an question in Section E the system is considered a significant threat
If you have answeredy y q y g ,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance.with 310 CMR
15.304. The system owner should contact.the appropriate regional office of the Department.
4
Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
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?
P q P g P
✓ _ 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
✓ Existing infonriation. For example;a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part.0 is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTIONYORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual):. 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0 {
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): Yes
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown "
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow.(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no)':
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped in 2006-per owner
Was system pumped as part of the inspection.(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
A leach field was added in 1996-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
BUILDING SEWER(locate on site plan) '
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 10"
Material of construction: ✓: concrete ._metal _fiberglass polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2„
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 5"
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: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations; inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.).
Tees were present. The inlet steel cover was to grade. There did not appear to be an sy ivns of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Conunents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Oyster Place Road
Cotuit, MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):..
DISTRIBUTION BOX: resent✓ if must be opened)(locate
( p p )( eon site plan)
Depth of liquid level above outlet invert: Even
Conunents(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:):
Theme were no signs ofsolids or backup.
PUMP CHAMBER: 2 (locate on site plan)
Pumps in working order(yes or no): Yes
Alarms in working order(yes or no) Yes
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
The pump in the chamber for the cottage was not working. A new pump was installed The pump for the house was in workiin
order.
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 Oyster Place Road
Cotuit. MA
Owner: Paul Cain
Date of Inspection: September 16, 2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching.pits,number:
✓ leaching chambers,number: 3 CWtecs w/stone(per as built)
leaching galleries,number:
✓ leaching trenches,number, length: ,2-.35'x 2'trenches(per as built)
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.):
Steel covers were to grade. There did not appear to be any signs of failure
CESSPOOLS: None (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: l
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):: '
Comments .(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth.of solids:
Continents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 Dvsrer Place Road
Condt, MA
Owner:. Paul.Cain
Date of Inspection: September 16. 2007
sxExcx
OF SEWAGE DISPOSAL
SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchtnark5. Locate all wells within 100 feet. Locate where public water supply enters the building.
com�g�
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� yg1�o A '
Q
a- 3o. Y�
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o
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 Oyster Place Road
Cotuit. MA -
Owner: Paul Cain
Date of Inspection: September 16 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 6'+1 feet
Please indicate(check)all methods used to'determine the high ground water elevation:
Obtained from system design plans on record-If checked,-date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
you established the high You must describe how y ground water elevation:g
Using Barnstable topographic and water contours maps the maps were showing approximately 6'+1-to ground water at this
site The SAS is in a raised system approximately 15'to ground water.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future: There have been no warranties.or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report an cny components of the septic system which have not
been located and inspected.
11 ,
L
Town of Barnstable
�oF the r
Regulatory Services
RA"STABLE, : Thomas F. Geiler, Director
A,E1639. Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town 'of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
Q:ISEPTICOisclaimer Private Septic Inspections.DOC
i
r. TOWN OF B11 ARNSTABLE
1 OC_,ATION � Uhl / O/AcL �e SEWAGE#
;VILLAGE ASSESSOR'S MAP&PARCEL 03S" to/
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY t CM 4V L 1 PUMP GH/.IA 611
LEACHING FACILITY.(type) (size)
NO.OF BEDROOMS
OWNER
P K
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 �/1S'n��'j'►o^ S FBrG !�� 0�
rp D
r
c�
a
TOWN OF BARNSTABLE
LOCATION ?3 0`S+f-' PIaC,,*, P,D SEWAGE #
ASSESSOR'S MAP & LOT&,'�'-AS1
INSTALLER'S NAME& PHONE NO.'-Ta f. Mi2CQ M)D,-C
SEPTIC TANK CAPACITY a Hen PL2 rn P (',hca M h e(`
LEACHING FACILITY: (type)�� Chn C P 4`5 (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATEV� �'� h.
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 /G�/���� 1 ►�/1
tr
7
�It�t9
i t
_ / O
President: 33 NORTH MAIN ST.
ROBERT BRUCE ELDREDGE;B.S.C.E., R.L.S. SOUTH YARMOUTH -MlCa.02664
Office Manager: Tel. (617) 398-2246
RICHARD J. O HEARN, B.S.C.E., Assoc. A.E. 81dredge Surveying Co.
Field Supervisor: (FORMERLY CHARLES N. SAVERY, INC.( CAPE COD SOCIETY Member of:
ROBERT W. KING PROFESSIONAL
Materials Testing: ENGINEERS AND LAND SURVEYORS
PHILIP WEINBERG, P.E., R.L.S. MASS. ASSOC. OF LAND SURVEYORS
AND CIVIL ENGINEERS
Structural Design Consultant: AMERICAN CONGRESS ON
EDGAR R. FAELTEN, P.E. SURVEYING AND MAPPING
i
d
August 25, 1977
Barnstable Board of Health
Barnstable Town Hall
F
Hyannis, Ma. 02601
Gentlemen:
A.. .
0,:�,
This is to certify that the Sanitary Sewerage" Disposal System has been constucted
Co-
substantially as shown on a planentitle'd, Sanitary Sewer Disposal System in Co-
'44t.
tuit for Frederic P. Claussen, scale 111 20' dated Sept. 3, 1976 by Eldredge
Engineering Co. Inc., plk umber,lies ing76056:-� µ
If there are any quest As please ¢coh act me at this office.
a Very truly yours, 1
6
Robert P. Bunikis
Eldredge Engineering Co. Inca
712 Main Street
Hyannis, Ma. 02601
RPB/ag
cc: Mr. John Grant
r� C
F /"�I
NOTES
PROP. WATERTIGHT COVER TO GRADE
LEGEND ,. DATUM IS •
NAVD 88 t ' SYSTEM DESIGN. ALARM AND CONTROL PANEL o�
TO BE INSTALLED INSIDE PROVIDE QUICK DISCONNECT FOR PUMP
2. MUNICIPAL WATER IS EXISTING
BUILDING. ALARM TO BE ON
SEPARATE CIRCUIT FROM PUMP
99- EXISTING CONTOUR o
X 99.1 EXIST. SPOT ELEV. 3. MINIMUM PIPE PITCH TO BE 1y8" PER FOOT. GARBAGE DISPOSER IS NOT ALLOWED PROPOSED
4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS STAIRS
-[99]- PROPOSED CONTOUR Cb
TO BE AASHO H-2Q TANKS (H-1O LEACHING) EXISTING 4 BEDROOM DISPOSAL WORKS CONSTRUCTION PERMIT \//�//\/ ��//\�\/��\ \ �\\/ y//y///\\//\ Q Sc
,�I-� ;`,ii?`,�i�` POINTS Soo/
DESIGN FLOW: 4 BEDROOMS ® 110 GPD = 440 GPD 0 198•41 PROPOSED SPOT EL. 5. PIPE JOINTS TO BE MADE WATERTIGHT. - - SEE PROFILE NO LOW t.
TH1 USE A 440 GPD DESIGN FLOW
6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH 5
TEST HOLE PROVIDE 84' OF 40 MIL LINER. AT 5' 1000 GAL. H--10 S/ " PRESSURE LINE �- �ti Locus
310 CMR 15.000 (TITLE 5.) OFF SAS_.IN,AREA SHOWN. TOP AT D 600 GAL.+ SLOPE TO DRAIN BACK TO PC
27. SLOPE OF GROUND 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO SEPTIC TANK: 440 GPD (2) = 880 ELEV. 21.0', BOTTOM AT EL. 16.0't FLOAT SWITCH ALARM ON RESERVE:: �� Cotuit
BE USED FOR LOT LINE STAKING OR ANY OTHER
SETTINGS: 0.25" WEEP HOLES
8 er She// B/uff
USE A 1500 GAL. SEPTIC TANK '` '� PROPOSED PUMP ON „ CHECK VALVE Bay
COL) UTILITY POLE PURPOSE. AND A 1500 GAL. NitROE TANK
8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. � � ° � COBBLESTONE 4" WORKING RANGE r
AND A 1000 GAL. PUMP CHAMBER APRON W/ 4„ MYERS SRM 4
FIRE HYDRANT .- SUBMERSIBLE 4 10 HP PUMP
5' REMOVAL OF UNSUITABLE SOIL REQUIRED �,` I o RETRACTABLE PUMP OFF 12" SYSTEM (OR EQUAL) Pine ;9e Hull
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING 9• COMPONENTS NOT TO BE BACKFILLED OR CONCEALED AROUND PERIMETER OF LEACHING FACILITY, BOLLARDS AT
WITHOUT INSPECTION BY BOARD OF HEALTH AND LEACHING: DOWN TO SUITABLE SOIL LAYER. REPLACE `L.
PERMISSION OBTAINED FROM BOARD OF HEALTH. SIDES: 2 (40 -I- 10) 2 (.74) = 148 GPD WITH CLEAN MED. SAND, TO MEET / TH � � � � LOT LINE oo�0000 ��o 0 0000
10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING SPECIFICATIONS OF 310 CMR 15.255(3) PUMP 1�1P C11A1�1BER
( o
DIGSAFE 1-888-344-7233) AND VERIFYING THE BOTTOM 40 X 10 (.74) = 296 GPD 70/ rye, �
LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES 600 SF 444 GPD (NOT TO SCALE)
TOTAL: . .
PRIOR TO COMMENCEMENT OF WORK. MAP 35 PARCEL 90 M P 3
WATERPROOF/WATERTIGHT
DJ MACKINNON PA CEL 101 LOCUS MAP
11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE USE (3) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
REMOVED 5' BENEATH AND AROUND THE PROPOSED � 14, 71 S. SCALE 1"=2000'f
LEACHING FACILITY. WN/
WITH 2.25 STONE AT ENDS 5 BETWEEN UNITS AND 2.6 ASSESSORS MAP 35 PARCEL 101
' ,A i ••'�•°
AT SIDES
12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND ��
REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
_ -- a 5� .:::;� �- � ° •� _ _ ._ _ _ _ _ , LOCUS._ISWITHIN .FEMA FLOOD ZONE VE (EL.. 14)
5• E}.': VARIANCES..REQUESTED:
13. ACCESS FOR ROUTINE MAINTENANCE MUST BE \ AS SHOWN ON COMMUNITY PANEL #25001 CO583J
PROVIDED FOR ZABEL FILTER. INSTALLER MUST FOLLOW k/ � 310 CMR 15.213 1 DATED 7 16 2014
MANUFACTURER'S SEPCIFICATIONS FOR PROPER FILTER MA ` 24 Jr ` �� y ,�Q 4 INSTALLATION OF A SEPTIC TANK IN A VELOCITY ZONE
INSTALLATION. APPROVED DATE BOARD OF HEALTH /
........ /' UNDER MAX. FEASIBLE COMPLIANCE 15.405:
14. INSTALLER TO VERIFY THE ELECTRICAL SYSTEM IS
' `"`"'"•' a (1f): REDUCTION IN SETBACK, SEPTIC TANK TO COASTAL BANK (25 TO 0')
SUITABLE FOR PUMP CONNECTION. ELECTRICAL PERMIT ) 1� / ;� / O (1f): REDUCTION IN SETBACK, SAS TO COASTAL BANK (25' TO 0')
REQUIRED. ( O (10): REDUCTION IN SETBACK, SAS TO LOT LINE (10' TO 1')
6
CO UNDER TOWN OF BARNSTABLE HEALTH REGULATIONS:
2 I t O d (VIII): REDUCTION IN SETBACK, SAS TO COASTAL BANK (100' TO 0')
D l' NOTE: CEDAR TREES �4 z & SEPTIC TANK TO COASTAL BANK (100' TO 0')
GB/ O PROPOSED TO BE RELOCATED
2 LINCY� O O ALONG LOT LINE
R 6
�0 1
EPLrs
AT �S Exsr,Nc DWELLING TEST HOLE LOGS
TANK WALL OUTSIDE OF TANK TOP GENERAL NOTES: GR T S 6 i 8 #33 OYSTER PLACE
DISTANCE VARIES 6"(TYP) 1. CONFIRM ALL HOLE LOCATIONS PRIOR TO R E 1 OAD
INSTALLATION. WOOD N TAI �� ENGINEER: CRAIG J. FERRARI, SE #13871
TANK WALL 2. ALL MEASUREMENTS FROM OUTSIDE EDGE OF TANK •
::::::. r::.
6"(TYP) TOP. ...... ..... .. 0 WITNESS: DONALD DESMARAIS
Y U 3. NitROE 2KS TANK TOP TO HAVE THREE-24",TWO-12" AND ^O �I\ k X J / ,,/ 4 ;
z O MULTIPLE 4"DIAMETER ACCESS HOLES WITH RISERS AND ''\ 9 3O 2020
INFLUENT a °° d COVERS FOR MAINTENANCE AND SAMPLING. . ! \ ;•:;;;•;:•;; ::::: :..: ,� OFF 7 DATE: / /
SAMPLING PIPE - W 4. FOR THE 24"HOLES;PROVIDE 24"DIAMETER CONCRETE 1 v ' 1
/�2"ID PIPE) M W O RISERS WITH CAST IRON COVER TO BE 6"BELOW GROUND /,�O \\ DECK ,::�.::.::::: < 2 MIN/INCH
PERC. RATE _
SEE NOTE 8 SUBMERGED - pH SURFACE AND SECURED TO TANK TOP.
° AERATION = DENITRIFICATION N _j 5. FOR THE12"HOLES;USEADSPIPE(CORRUGATED)AND ORN ENTA F I 20-201
~ INFLUENT CD Q POLYLOK(OR EQUIVALENT)COVERS TO 6"BELOW / G SE
\ �/• �P� �^ . CLASS SOILS P#
CHAMBER z CHAMBER =
o p GROUND SURFACE AND SECURE TO TANK TOP. r \
M (SAC) (DC) zo 6. INSTALL 4"DIAMETER PIPE(3"BELOW GROUND ! LAWN ��
O � SURFACE)WITH FERNCO RUBBER CAP.INSTALL WITH A ELEV. 2 ELEV.
� ~ 6"ROUND VALVE BOX AND COVER TO BE FLUSH WITH -\� \ O" 2O' D" 19'
o z a ~ o EFFLUENT , \
v, a w p - J a THE GROUND SURFACE. ,
U_ � 7. HOLES H6 THROUGH HI ARE 4"DIAMETER HOLES FOR 4 NEYSUCKLE /• <
0 o u z D TO TITLE 5 SOIL AERATION TUBING AND PULL CORDS. INSTALL 4" F
W o - o e OF \ BENCHMARK: FILL FILL
EXISTING ° - ABSORPTION DIAMETER(6"BELOW GROUND SURFACE)WITH CAP. \ CATCH BASIN 6" 6"
SEPTIC TANK a -� SYSTEM 8. FOR EXISTING SEPTIC TANK,PROVIDE 2"DIAMETER 10 \ I\ =2.7' NAVD$$
(NOT To SCALE) O (SAS) SAMPLING PIPE THAT IS CEMENTED OR ANCHORED TO '
a a TO BE POSITIONED 6 TO 12THE TANK TOP AND EXTNDFROM THE EDGE OF THE D
50' 0
2"BELOW TANK TOP
\ FF A A
OUTLET END OF THE SEPTIC TANK OR IN THE SEPTIC Ar. - � � fG ,,• � ° ` _�_ _ LS •: ;:L�;> J
TA*.;:CONCRETE OUTLET COVER. ON THE .... EIaC Or
_. c7. .: - _ �_.
y`R
NOTE:FOR NEW THE SEPTIC TANK THE 2"DIAMETER SAMPLING PIPE \ GJ \ 1 0YR 3 2 10YR 3 2
SEE NOTES 5 AND 6(TYP). SEE NOTE 4(TYP). • \ N 26 �\, ( „ / /
ENHANCED SETTLING SEE NOTES 5 AND 6(TYP). SHOULD EXTEND TO 2"BELOW THE GROUND SURFACE 29 01 �6 20 24
TANK(EST) AND HAVE A 6"DIAMETER PLASTIC ROUND BOX AND FQC !�
SEE EST DRAWING _TOTAL TANK TOP COVER AT GROUND SURFACE. F �,�" �� // I B B
GROUND SURFACE(TYP)- - - - - - - - - - - - - - - - - - LENGTH=139" - �I� \ E .'..;'_:?; j G� ��
4E(TYPOTE SEE POTE TOTAL TANK TOP \ w i 0 / LS LS
WIDTH=73"
SEE NOTE 8(TYP) / r �`
6"TANK (TANK TOP HAS 1/2" � f��/ \ / � 10YR 5/8 10YR 5/8
CEMENT WATERSTOP TOP(TYP) BEVEL/TAPER) \\ ( DFF / \ \\ /A0 // / \ 42 15.5 48" 15'
INFLUENT ,
48"STATIC
\ /P FIRE PIT X� 1� // C C
WATER DEPTH
``AA
EXISTING -.- _.-.-..........- -. ...... - -•-• - 1 �/ � �� �.�rj/RS PERC
SEPTIC TANK w LL _ _ - TO SOIL /X \ / 4 - //
(NOT TO SCALE) N p W � Y LL ABSORPTION SYSTEM w // / C
1 SUBMERGED o _ z Y w z \ / / / / MS MS
� = wa 1 AERATION � � ¢ pa � w� (SAS)
a z o CHAMBER w DENITRIFICATION o --00 o U_J f- a EFFLUENT �� / O
w - o CHAMBER y
I- o _ (SAC) o w p Q z w w z LAWN AREA �-� �'
o °z W - (DC)-� J o ° o LL 3: w° _ (FORMER �% / �j 2.5Y 7/4 2.5Y 7/4
J
LO Liz o "' o r w CZ DREDGE // c3` -, 132" 9' 132" $'
SPOIL AREA) Mq,Qsy j
� NO GROUNDWATER ENCOUNTERED
•.� •• ND OU
0 0 0 0 0 o ELEV. 0" KleanTu LLC �i LICENSED STONE ���'
TANK BorroM PIER/WHARF LICENSE i
THICKNESS 6" CRUSHED AGGREGATE OR APPROVED PLAN AND CROSS-SECTION FOR 3476
TANK WALL MATERIAL(DEPTH TBD-6"MIN);ON LEVEL, ENGINEERING DESIGN ) 'v
THICKNESS(6") COMPACTED AND STABLE BASE NitROE0 2KS WASTEWATER TREATMENT / O �� ,; �\ PB 105 PG 4.1 n, 1
SYSTEM (WWTS) �`Z`/
N-ASST152M-H20 v y' I T E L A N
BUOYANCY CALCS:
, ^
O
H-10 1000 GAL. PC WEIGHS 17,250 LBS
2.8' x 9.0 x 5.25 X 62.4 = 8,255 LBS UP (OK) \
1.
/ OF
H-20 1500 GAL. ST (NitROE) WEIGHS 23,000 LBS /
2.5' x 11.0 x 6.1 x 62.4 = 10,468 LBS UP (OK) #33 OYSTER PLACE ROAD
i c i� MLi -2
H-20 1500 GAL, ST WEIGHS 23,000 LBS
2-.2' x 11 .0 x 6.1 x 62.4 = 9,212 LBS UP (OK) ter, 'p COTUIT, MA
SYSTEM PROFILE
ALL SYSTEM COMPONENTS SHALL BE
(NOT TO SCALE)
MARKED WITH MAGNETIC TAPE OR S� PREPARED FOR
PROVIDE MIN. 20" DIAM. WATERTIGHT COMPARABLE MEANS FOR FUTURE LOCATION.
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE PROVIDE MIN: S DIAM. WATERTIGHT PROVIDE MIN. 20" DIAM. WATERTIGHT A T T H E W J M A C K i N N O N, TRUST E,
ACCESS COVERS TO GRADE ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE r
\ 2" PEASTONE OR GEOTEXTILE ■
FILTER FABRIC OVER STONE
i t;
6-8' MINIM 7 COVER OVER PRECAST 6-$'
MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 27"I SLOPE REQUIRED OVER SYSTEM 33 OYSTER PLACE REALTY TRUST
PRECAST H-10 NOTE: 2" MIN. WALL ; BLOCKS OR
RISERS (TYP.) THICKNESS REQUIRED MORTAR ALL PRECAST RISERS
PROP. TEE 4 OSCH40 PVC COMPONENTS H-10 INV'S EL. ,Z ` (t DATE: SEPTEMBER 8, 2021
PIPES LEVEL 1ST 2' j 20.20' �L
* ENDS BET. SIDES i (H M
1500 GAL H-20 14" 5' OF As p ,i.
5.0 1000 GAL H-20 21.03 f s I
10" , " , l LSNOFA�gs �
4.55 SEPTIC TANK TEE 10 PUMP CHAMBER o 0 0 0
V.I.F. TEE 4.30 4.25 4.00 °° ° 0000gogo '�� DANIEL
o 0 0 0 :. .• i. oY°o o :. .'••:i. o 0 0 o 9
NitROE TANK 3.95 TEE ®®®® ® ®� o 0 0 ®®®hJ -I2®®® ' jb: Cti 4;
SEE DETAIL ' o 0 0 0 '.0000° '.°'.0000° t A. `emu` O D,4PJI LA. ,
GAS BAFFLE .:• SEE DETAIL . o 0 0 0 0 0 0 0 ° ®®®®�®®��®� o0 0 0 o o ° o o + v
0000 ° ° 0000 ' t Scale: 1 = 20 0 0 0 0 0 0 > 0 0 0 o 0 0 o 0 0 0 , i ,-
°O°O°O°O°O°O >°°°o°0 0 ®®®®®®®�J�®® °po°o° ®®®®®®®®®�® °°°'.000'.,, U,ALA u OJALA
'-On0„O„O„°- >O°O°O coo 00°O°O ,O°O°O°O° -1 r
ABOVE >00000000 ®®®®®®®E� ®® o00000 ®®®®®®®®®®® .o00o0o00 r:. ;_o ago CIVIL
4 LIQ. LEVEL (ACME OR EQUAL) , o 0 o ° o 0 0 0 0 o
+ �0000000° •000�oo '00000000 18.2D' �.� �f. �P I)F 4
9
` 20.53 20.36 Hof it s No.46502 /fhb
0 FP S�p� Fss�° ` �' o "a 0 10 20 30 40 50 FEET
0 0 0 0 0 00 0 0 0 0 0 0 o;0 o;0 0 0 o •`•''` '•' ' .."'Y. �`, `�+\, - !p �•�'
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o 0 0•
°O°o°°o°°o° °°n° °°°o°°o°°o°°o°o°Oo°o°o°o°n°oo9n°o°°o°Do. o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°o°O°o°°o°o °o•o'o 0 0•o 0 0•o 0 0 0 0�o 0 0 0 0 0 0 0°, O� "iCyG S U E V `DANIEL �/\' ER ��� a
o ^ ,0000°,'.°n°non°,°o°"00000o°0°0°�4�4°°�ogoOo°o. 000000000000000000°000°0°0000000000000°0°0°0° DANIEL ?. ��G,
0000000000000000000000. H-10500 GAL. LEACHING CHAMBERS BY ACME PRECAST `^ g �•
•+,o,,o„o_o_n_�_o.o 0 0 0 0 0 o-r•_0_n_o_0.0 0 3 UNITS REQUIRED v A. N v L�VIL �' `� !A_�i � off 508-362-4541
3/4"-1-1/2" DOUBLE WASHED STONE O OJALA fax 508-362-9880
6" CRUSHED STONE OR MECHANICAL 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 4C' X 10' ANo.40980 No.46502 �� I downcope.com
COMPACTION. (15.221 [2]) COMPACTION. (15.221 [2]) 'Cq 'CISo �gfSS\OAo ' sONAL��NG\� low� do Cape eh ineefi/3 I/!C.
9 SURVE 8 gj
(2.5% SLOPE) ( 2 % SLOPE) ( 2 % SLOPE) ( 1 % SLOPE)
civil engineers
12' 2' 2' 80' LEACHING s.o' BOTTOM�'TH-t g-2021 r^ .1 loud surveyors
FOUNDATION SEPTIC TANK NitROE TANK PUMP CHAMBER D BOX 16 FACILITY NO GROUNDWATER FOUND 939 Main Street ( Rte 6A)
DATE ANIEL A. OJALA, P'E., .L.S.
YARMOUTHPORT MA 02675
BICE # 19-317
19-317
14-9A
COTU/T
BAY
ST. YSTER PL.RD. O \\���
Q LOCUS
am-M28Sc N
r�
�J
SCO1{p� '��
2�0 C� \
�p0 O
LOCUS MAP °=
SCALE I"=2000'
ZONING DISTRICT — R F
, 2
O�
LO _
�� 5 Outlet Dts�ribtttion — ,,
! gox with Bari le,. -- - -
�est m``
VG nte.i %� 3' 1
/Qot �`�►
0�
OVA 20.10f
S7 4'50"W
Wader fiighf Pump Chamber 8 -�
to be provided b us1n9 oo` r1P\
600 Gallon preca-� Sep> kc Tan K-
*R. covers 5et to grade k sealed � �2� �C'
2 e,�
D
� Q�oQ
°a W
1000 Gallon wa}er +,gh )ow
prof i le- Septic. TanK (UJeighted down) 6 u
M.H. Coers 5ef t0 grade s$ ealed . ♦ S.F o
22,550 _ To M.L.W. �
Q
G N E,R_A L N OT L S
LEACHING TRENCH ; Provide, rninirnum 12 depth of a
3/4To )VZ washed sto,-,e, free from iron fines and
I
du5+ uncler perfcrafed plasticdistribution pipes 4-1 -
Enc15 of distribution hne-5 +o be plugged. O
MTRIBOT)ON BOX 5 Owlet box which provtJes
a %,uitt to bafft� YE_ prr,rnCi,ded Ln.;t to be- Vvinde..
wa+cr tight' acid ve_n+e-d. Ouflet pipes from
disf ribu+ion box Shall be laud level fora di5t. of 4' D '
PU M P CHAMBLR 600 Gallon precast Septic
Tank recon,rnendeci (Ameeicari Precast ) ore9ual. ;
Chamber to be- weighted down because o� h;q Exist 9
9r.>tind wafer. Chamber and manhole +o be made
wafer +;gh} and nianhoie cover b,-c,,49h+ to
grade and 5eale-d. ?urr,p t,o be Sep t0 pump N C@SSpOOI
659ailons per cycle.This w111 doze- +renc ie-s +o a 0
dop+h of ;/'2 ' per c�cle • NN
SEPTIC TARK : 1000 Gallon low pro�ile (Amertcart ~ M O
Precas} or equal recomrnenc�ecl 1Jni� �o be ��eighter� Z N
cl�wn becau#se of high ground water anti rr""tcle. ,-a ,er -
tic)ht, Manhole covers broLi�h +ograola and Sealed .
4 Olt
--------------------
13cdrnS/ i. D/ 0 0
Cn
m
0
Wg11
�. Retaining
-Z
SHEET I OF 2
SANITARY SEWER DISPOSAL SYSTEM
IN
Bo,Q COTUIT BARN STABLE MASS.
FOR
FREDERIC P. CLAUSSEN
DRAWNS S.
R SCALE . 1 " = 20'
Bench Mark � -- --- -- :
CHECKED BY DATE SEPT. 3 1976 a •�+�'"" M
U.S.0 & G. Survey Disc M2_8SC- Elev.= 38.22 R.P & "....30
ELDREDGE ENGINEERING CO. INCI \1R•,$TE���
_ U
µ REGISTERED C7/11- ENGINEERS & LAND SURVEI
712 Mid 1 ST 30 NO. MAIN ST.
NY,-;^�I`; IS, MASS. SO. YARMOUTH,MASS. NZ 76056
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