HomeMy WebLinkAbout0029 PATIENCE LANE - Health '29'Patierice.L'ane
Cotuit
TOWN OF BARNSTABLE
LOCATION Qa:�'1 Q V\C- -- SEWAGE# y
VILLAGE �Tc�. }' ASSESSOR'S MAP /&^PARCEL
INSTALLER'S NAME&PHONE NO. C w`aO-
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS
OWNER
PERMIT DATE: / ' 1 �-d I 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) 1 Feet
FURNISHED BY C°� S
1 Ir
A 3 3J
� o
13
a 03
G --a -33
No. � t 3 Lf Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for misposal 6pstem (Construction permit
Application for a Permit to Construct( ) Repair(1/) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. q o,+)e`\&- LJ es e Owner's Name,Address,and Tel.No. Ko--., Ma rq►.�e
LbT QI/ cat"A
( 0
Assessor's Map/Parcel O3 6 50,10-1 ZZ.(o(oy
Installer's Z4ame,Address,an Tel.No. Sbg- Y 7 7- 7 7 Designer's Name,Address,and Tel.No.
53 C_,,5MA,eCc,4,A �}
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 3:.V S O« JL6 C ay.�dlc-vv11_ 6
CO1AALii6 ki)2� inuqqr Eiov�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by LS
Date 16-M
Application Disapproved by Date
for the following reasons
Permit No.- 00�r 3 Date Issued
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS '' Entered incomputeri
Yes
PUBLIC.-HEALTH DIVISION - TOWN OF BARNSTABLE; MASSACHUSETTS
ftplitatioft for,-Pisposaf 6pstPtn Construction Permit,.,,,
Application for a Permit to Construct(. ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.o� o."�-i Lv��Q,` Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel O3 6q? �`"�4-� ��-477-1o(py
Installer's ame,Address,antTel.No. SC'9- Y'7-7- 77 Designer's Name,Address,and Tel.No.
Cam. �
Type of Building:
j
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures r J1
Design Flow(min.required) gpd Design flow provided Aj llft-
gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
i
t`
Niture of Repairs or Alterations(Answer when applicable) �ytS r.�
, r1 '
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system,in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed - + Date
S
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. (`" 3_��..(• <� Date Issued (a ( r l
jTHE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
rF l�J
A Certificate of Compliance
THIS IS TO CERTIFY,that the On-site�ewage Disposal system Constructed( ) Repaired(V) Upgraded( )
Abandoned
//( )by
at a g �"p,� k�.G� W has been constructed in accordance
with the provisions of Title 5 and th or Disposal System Construction Permit No. a011- 31fl dated
Installer `>' Designer
#bedrooms -3 Approved design flow gpd.
The issuance of this permit shall no4 e constr ed as'a guarantee that the system wilffunction a-de is fined
Date �` Inspector
---------------------
-
No. po//- 31-17 l- Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal *pstrm construction i3Prmit
Permission is hereby granted to Construct( )`•\ Repair Upgrade( ) Abandon( )
0
System located at ( o-ti Q�^c (✓�- e C a'r�� -
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.----
Date �O�1 _ ( Approved by
tf
,r
GF SHE TQ�
Town of Barnstable Barnstable
Regulatoryl> IIA Services Department a�,e;caca„
RNSCABLE. ,
1
639: Public Health Division
�ArfD MAC a
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 / - O , e Thomas F.Geiler,Director
FAX: 508-790-6304 / �/ Thomas A.McKean,CHO
CERTIFIED MAIL# 7011 0470 00001 4525 7611
August 23, 2011
Karen Marquette
29 Patience Lane
Cotuit, MA 02635
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 29 Patience, Cotuit,MA was last inspected on
August 4, 2011,by Sean M. Jones, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR-15.00) due to the following:
• D-Box was rotted at the water line and needs to be replaced..
The evaluation report shall be submitted to the Health Division office within two (2)
years from the date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD.OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, r ,{
use only the tab 1. Inspector.
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
C Company
e Enterprises
� Company Name
153 Commercial St.
Company Address
Mashpee Ma. 02649
Cityrrown State Zip Code
508477-8877 SI 4522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes Z =Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
W�
59 Q
8/4/2011 � -
Inspector's Signature . pate
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this:inspection:If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and_the system owner shkUPsubr6t 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 tla e.future under
the same or different conditions of use. Y
e. .
t5ins•11110 Title 5 Official Inspection Form:Subsudece D i. _.<�w>...r. I nspecb Sewa98 � .
Commonwealth of Massachusetts
T
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. City/Town State Zip Code Date of Inspection
B. Certification (coat.)
Inspection Summary: Check A,BC,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 exfiftration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by 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 Iess than 20 years old'is.available.
❑ Y ❑ N ❑ Nb(Explain below):
Title 5 Official Inspection Form:Subsurface Di System•P 2 17
15ins•11l10 Olfi S e of
v speck Sewage Disposal yst Page
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�y 29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B,) System Conditionally,Passes(cunt.):
❑ 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):
Distribution box was found to be rotted at the water line allowing roots to penetrate inside.
J
❑ 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):
El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a mannerwhich 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•11110 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
°t 29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
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:
❑ 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 %day flow
t5ins-11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachuseft
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owners Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. City/Town state Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
-from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is:a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The'system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
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 flailed. 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.
15ins•11/1 D Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
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
El ® 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): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
JTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2009=26,000 total =71 gpd 2010=3,000 total=8 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: vacant
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-11/10 We 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°< 29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 ®fficial Inspection i=orm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y< 29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
original system installed 1985 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade: 1
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: 1006 gallons
Sludge depth:
5"
t5ins•11f10 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
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is Cotuit Ma. 02635 8/4/2011
required for every
page. City/Town State Zip Code Date of Inspection
D. System. Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 3.5'
Scum thickness
2"
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? opened covers and took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years as
maintenance. outlet baffle intact and in good condition,water level was at bottom of outlet invert.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
0 concrete ❑ metal El 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 10 of 17
Commonwealth of Massachusetts "
Title 5 Official Inspection Form
UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. -02635 8/4/2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
'liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ .No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was rotted at the water line and needs to be replaced.
Pum
p 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.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
. Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owners Name
information is required for every Cotuit Ma: 02635 8/4/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information-(cont.)
Type:
® leaching pits number: 1 x1000 gallons
❑ leaching chambers number.
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
El innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of
vegetation, etc.):
at time of inspection the leach pit had approx 1' of standing water and no signs of past hydraulic
overloading.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth ofMassachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
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
5 �
14-f (2 0
P ?y°
07- 03
A-2 23F
G-Z 32
P
A3 31a
t5ins-11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 15 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Patience Lane
Property Address
Karen Marquette
Owner owner's Name
information is required for every Cotuit Ma. 02635 8/4/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
Shallow wells
Estimated depth to high ground water. 20+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan,reviewed: Date
❑ Observed site(abutting property/observation.hole within 150 feet of SAS)
❑ Checked with local Board of.Health-explain:
Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-11/10 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
29 Patience Lane
Property Address
Karen Marquette
Owner Owner's Name
information is required for every Cotuit . Ma. 02635 8/4/2011
page. Cityrrown State Zip Code Date of Inspedion
E. Report Completeness Checklist
® Inspection Summary: A, B,C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information-Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 6 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
h
No..fJr.� r77 F�s.. � -...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
-' i- v�1..t ..... OF........ t .............................
Applir�atiou fur �iupuuaal arks Tomitrurtiuu Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................__...... A-.T.lJE E.,..... A1' .. -�-c1D - -
Locat'o -Address or Lot No.
........... c�:r�1� . .�.._.... . KMPA............................ ..............`l�.�l�_...�i._�S_. �...�....��i��-
� owner ddress
a ► ..........
..._.. .: .0�.....C�.............. L�1�' �. ... .. {If �e ..
Installer Addr ss
Type of Building Size Lot...�%Q j l4P---------Sq. feet
Dwelling—No. of Bedrooms.__...................................Expansion Attic (V/) Garbage Grinder ((V�
f�l/1� No. of persons............................ Showers — Cafeteria
Other—Type of Building .................. p � ( ) ( )
G" Other fixtures -----•-----•---------------------- ---
W Design Flow................—`._-Z ------------gallons per person�PGr day. Total daily flow...... �_O.__................-.....gallons.
W Septic Tank—Liquid capacity.l PPd .gallons Length___—F�k"�Width-_�"�ti _ Diameter-.1v -----
Depth-. �'_ .__.
x Disposal Trench—No._nIIA......... Width.................... Total Length.....................•Total leaching area........____.-------sq. ft.
Seepage Pit No........./.......... Diameter.........t ..... Depth below inlet...... .......... Total leaching area.... - ...sq. ft.
Z Other Distribution box Dosing tank14 )
MGon/NoII Date........................................
Test Results Performed by..._ ........ ...............•_.___�'....._.__.�._____
aTest Pit No. 1_...". .- .minutes per inch Dept i of Test Pit.._._.1 ._...__ Depth to ground water_./ Q .........
f3:4 Test Pit No. 2................minutes per inch Depth of Test Pit-_-_-__--..____---. Depth to ground water........................
--------•----------------------•--------------------------
•---------------
•.......
-----------------
�u��Or ----------•---------------------------------•-------•-------------------------------------..--
O Description of Soil--------<?--.��....---�-4. ---`f....................�-_
y, Am p . 4a
x ---------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-------------------------------------------------------------•---•--•------•....._.......---.......-------...-•--------------------------•-----------•----------•----------•--•---.....-••--•-••---•--
Agree t:
he ndersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
t pro io of`� T -- 5 o e State Sanitary Code— The undersigned further agrees not to place the system in
pe ion ntil C t ca Compliance has been •ssu�thef health.
Signed.----- .... .----------•....................•-•--- ------- ---��-``-------
ate
p'cam ion Approved BY -------- ................................ ...---
Date
Application Disapproved for the following reasons-................................................. -----•------------------------------..........................
-----•----•........................................••---•••..............•-•--•--•--.....--•--------•------.....--•-----------••----------------•-------------•------------------------•------....__..._
Date
PermitNo......................................................... Issued-.......................................................
Date
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... .......OF........7b.A�t,!! . _tLe...............................
Appliration for Disposal Iflarks Tonstrurtion Prrutit
Application,ii§ hereby made for a Permit to Construct O or Repair an Individual Sewage Disposal
System at:
. ....................... --------------------- ..............................LQ.-T--------- Li..................................
Loca ion,Address j or Lot Ko.
......k ........... .......... ...5AYear4...:�o....C UQ__4T__N,
.......Tb.i-kJ4....C-A.. ...I_b._q
Owner Address
..........?
.......... ...............
Installer Addi's's"
Type of Building Size Lot_ .Q)ISQ..........Sq. feet
U
Dwelling—No. of Bedrooms... ...............................Expansion Attic Garbage Grinder *4)
Other—Type of Building ./V)A.;............... No. of persons............................ Showers Cafeteria
114 i
Otherfixtures ---------------- :--------------------*---------------------------------------------------------------------------------
Design Flow............... ......................gallons.
. ....................gallons per person per day. Total daily aily flow-----Z.'�Q.
1:4 Septic Tank—Liquid capacity�PRQ---gallons Length._'&.-.k'.. Width..'.t'-_Ajt.. Diameter_A./�. ...... Depth.SL'
Disposal Trench—No...A11A.......... Width.................... Total Length......_............. Total leaching area....................sq. f t.
Seepage Pit No......../........... Diameter........I-q...... Depth below inlet._...A?........... Total leaching area..!6!.....sq. ft.
Z Other Distribution box (V) Dosing tank)
Performed by..Percolation Test Results ..................................... Date________________________________________
....minutesperinch De h of Test Pt---- I
Test Pit No. I... i .1a........ Depth to ground water._\10_,V9...........
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.___.............._. Depth to ground water._____..........._.._._.
9 .......................................
15�) L '--------------------------------------------------------------"*---------*--------------
0 Description of Soil.......O.-A......... ..................................................................................................
q.............................. . ..........Mal...35)
U 61VO.16 0 Me wo ...................................................................................
.. .............
-------------------------------------- ---------Mat--..��Mjv. .................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...................................................................................
.......................................................................................................................................................................................................
Agreem t
e dersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the rov. ions f T frIL-E, 5 the State Sanitary Code—The undersigned further agrees not to place the system in
era n u t ca Compliance has been issued by the board of health.
SI g ne d... .. ........... ............................................................ ..... 'a..------.
D. t;e
A li n Approved By------S ....... ............................ ...........
//Date
ication Disapproved for the following reasons:...............................................................................................................
.......................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....rWAI F 6 le-W Al.5
...............................0. .................... ........................................
fit
%awrtifirate of TOutpliaurr
THIS IS TO C h t the Individual Sewa&� Disposal System constructed or Repaired
# !(�). --- Ck-u-.ra�............................................................
by.............. ==�S= -Installer
at................. ---- ... 't---------------------------
............
has been installed in accordance with the provisions 87"TITT-F, 5 of The State Sanitary Cqdus/escribed in the
application for Disposal Works Construction Permit ........ date( ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....._.. 5 -t5
....e
.......................................................... Inspector--..--.... W........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... po�........................OF............ ......................................
No....0.. ...........
...........
Disposal Works Tonstruction "prrutit
Permission is hereby granted.---. .......3.........00-Z........................................................................................
to Construct (K) or�Repair an Indivi ual Sewage isposal System
at No. . ......jV ..........
Ig
.............. ... .................. ..........................................................
Street
as shown on the application for Disposal Works Construction Permit No.. Dated._.( . P1. .....................
......................— .............................
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
FIRE
IV
sG�riArvi�
. 6' B' rou.
O +— �� o o O
' Z 7117
' M
.SCJ
30%i s/
40 Sc•7. ,4 c!c r
a
().TCc-r0A,( P ��
.j`n
=c'$ ' c 'r , q gASJ.� To �� /3y�•' ws
Qj
Lj
i ca f'c 19367
LBERT
LEGEND. A. 124
EXISTING SPOT ELEVATION. OAO ;.ice tNl , 951 °-
EXISTING CONTOUR --- 0.--- - ; �,� IVI w� CERTIFIED PLOT PLAN
FINISHED SPOT ELEVATION [�J " '°`" GJSj- �•`a _ ie& L
FINISHED CONTOUR 0rrv�® / Gc�? ��{ T�
�
C,c? j_.�
NOTE: The location of any existing underg_ound sewerage, IN
wells, or other utilities shown on a is plan is approx-
imate only as determined from records and/or verbal d A ��� •�'�� , � ��
information. The contractor is responsible for the •i.Fl
verification of the existing locations in the field. SCALE, / " 40
DATE -
MGSON
LOREOGEENGINEERING CO. IN CLIENT.
i CERTIFY THAT THE PROPOSED
EaISTERE REGISTERED JOB .NO. o S� BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
ENO NEER URV DR.BY fl OF I3ARNSTAB E , MAS
712 MAIN STREET CH. 8Y
HYANN I S, MASS. SHEET OF Z" DA E REG. LAND SURVEYOR
+...:+•u.� •v ..M,...<.,.e....:a:� ..,..i.S..i,,. .r.;.'��*w:...•w+�.:.....asw.».,...^t: ,a:=:,.......->la'1ilUl..*., _.,«,... ..._Jd.:.
NOTE /F"F/TiHGR TNG�SEPTIC TANK OR i
j 20 FT. M//V. GE/ACt//nrG_ 'P/T ARE MORE TN A N /2"BFLO/'V
" /O FT. M/IV .�rR/1 DES 1•4�O/AM ETER G'ONCR.FTE. COiiER �/
S."ALL B.E ,9R0UGqT TO Gf{ApE.�.4N, EXTRA
� 1 E
4 PVC.PI P
CONC�PTE i h'EAVy CA ST /RO/y GOER Sf•/ALL QE USEO
/N OR/VEWA Y
COJVCRE'TE
{ G ApE CO i,ER CLEAN .SA A/O
1
A _ i
6
A
Ll UILO LEVEL -
.t
z LAYFR
4 •; SCt+EOvtaG4o
•' ./�K C. P/PE f 0"U f, �a � jIB GAC. • • . • . s . • a .' WASHED 57r/✓E
D/ST, • • • • • • • . .
SEPT/C TANK • . • • •
BOX v e 1 • r •,• • • .r• ° _
_ . WASHED STONE
." 7� x /.v � �if ► s. • • s • • • • • • s O EfA5
,•, PR7"SE•��6E:
s � . • • • • • • • • e o P/7OR EVU/✓-
INVPRT e`L.EVAT/DNS P!T.CA"�/� Cl��/ SS �.�c� Y •. , s
/Njff,RT AT OL/lLD/NG
/INET .SEPTIC TANK I t3.2 1O FT I O FT O1�41►'f• C CSFE Y�'l8UL.4TION>
' Ot/7LET SEPTIC TANK 1 v z.6.FT. -
lNLET D/STR/BUTIDN 80X ! FT GROVN 4)D HTER TABLE
SECT/ON O F
O(lTLETD/STRIBIIjyON BOX 1.oz.z F7
INLET LrACN/NG PIT 672-- cr S� A4CaE O/.S�O�S�L SY.S7'EM- -AJV4AT/DN.
L,EACH/NG A/T DjHENs/ON A 3 R'T
-SCALE %4
DRSISN FRITTER/A D/i•fF++VS/AlV
} NUiNSER.OF BEDROGI+lS 3 D/MANS/ON C" 4 FT. /hr^r
G^�4aAGE0/SPOS�1t UNIT SOIL LOG S®/at TEST
TOTAZ EST/M$tTED FLO*V 3 3 y SOIL TEST SOIL 77ESTO�2 _
A JMC OF 4 ACNING PITS ( F[EK 104 0 /+ELEY. pATE
a S/OE GEACH/NG PER P/T S4. FT p z i RESULTS IVITNESSED 8T �M ''�4"� �✓
007`TOM LEd1CYlAlCr PER FT- L,o ��' q` PwACOLA-r1ow RATIr jo/ Liss MN1oI/NCN
TOTAL LtACH/NG AREA 6SQ, FT. ` Sd �s=Y 01 PENCOL.I4T/ON RATE�2 ��'yM/N.�INCH
RESERVE LEACN/NG AREA -�SQ. F T.
7`E57' P, cye3 6
Lo T G /FA-77ENC�
—07
e ALBE RT, � r mr-r�t v
t �+ ROBEP,T
eF r R. r 117
o. 1095 11A i ' E" r� 01DREV6E
p�h^.� 95 ,m .ems, t a ,7 c, 7t2 MAIN .97r, HYANIV/9, MASS-
Lj
:
pC� �i5_-cF \,�4 /�GKL"v
QnfT /
, N
A GM U.Vo W-4 —_.V A EL EV JOB A00.
/ .� �:
3 '71SI
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME i ADDRESS
olnori R. fur Co. ejjne .
. Ire Ckf (,UQS�-e rn lorLcl N czl-i.; 1�C,.tr�l�i Gln
t U I L D E R OR OWNER
DATE PERMIT ISSUED g S.
DATE COMPLIANCE ISSUED 3iS
n