HomeMy WebLinkAbout0121 PEPPERCORN LANE - Health 121 PEPPERCORN LANE
COTUIT
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Commonwealth of Massachusetts Olt0
Title •5 Official_ Inspection Form
Subsurface Sewage:Disposal System Form-Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address t
Gale
Owner Owner's Na ► i
information is "
required for every COtuit V MA 02635 9/1/20
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information 4W /40L4
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
It
I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CM 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 Further Evaluation by the Local Approving Authority
4. ❑ Fails
9/1/20
Inspector ignatu-ref Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd::or-,greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions,at the time of inspection and under the
conditions of use at that time.This inspection°does not address how the system will perform,
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owner s Name
information is
required for every Cotuit MA 02635 9/1/20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
I ® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
i
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owner's Name
information is
required for every Cotuit MA 02635 9/1/20
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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owner's Name
information is
required for every Cotuit MA 02635 9/1/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections: 4.
Yes No
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Force:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Syste5Form 4Not for Voluntary Assessments
�r 121 Peppercorn Ln.
Property Address
Gale
Owner Owner's Name
information is '
required for every Cotuit MA 02635 9/1/20
page. Citylrown 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 a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
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
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owner s Name
information is
required for every Cotuit MA 02635 9/1/20
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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS,located on site?.
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information.For example, a plan at the Board of Health.
❑' ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5msp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form= Not for Voluntary Assessments
121 Peppercorn Ln. -
Property Address
Gale
Owner Owners Name
information is
required for every Cotuit MA 02635 9/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 5 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Description: -
5 bedroom permit and engineered plan on file at BOH
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 ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Seasonal -.
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
I
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owner's Name
information is
required for every Cotuit MA 02635 9/1/20
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: No recent pumping per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
f Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
f ,
Commonwealth of Massachusetts l
(e Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owners Name
information is
required for every Cotuit MA 02635 9/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
2000 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 24"
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
L; 121 Peppercorn Ln.
Property Address
Gale
Owner Owner's Name
information is
required for every Cotuit MA 02635 9/1/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 18"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
H-10 tank appears to be structurally sound
if tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
Sludge depth: 3„
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle
>2"
Distance from bottom of scum to bottom of outlet tee or baffle
>2
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owners Name
information is
required for every COtuit MA 02635 9/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate omsite plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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):
s "
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day _
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owner's Name
information is
required for every COtuit MA 02635 9/1/20
page. Cityrrown 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
4
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes [] No
9. Distribution Box(if present must be opened) (locate on site plan):
oilDepth of liquid level above outlet invert
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.):
H-10 d-box is 2'6" below grade and in very good condition
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of'18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owners Name
information is
required for every Cotuit MA 02635 9/1/20
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.):
* 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: 5
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ 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
I '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
u 121 Peppercorn Ln.
Property Address
Gale
Owner Owners Name
information is
required for every Cotuit MA 02635 9/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers were video inspected and are dry at this time, no indication of past hydraulic failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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f
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•u 121 Peppercorn Ln.
Property Address
Gale
Owner Owners Name
information is
required for every COtuit MA 02635 9/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner formation is Owner's Name
required for every COtuit MA 02635 9/1/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
a
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
I , 9/4/2020 Assessing As-Built Cards
TOWN OF/BARNSTABLE V
LOCATION 060/e��q 14 SEWAGE M-�����
VILLAGE —T%��T ASSESSOR'S MAP&LOT���3_J
INSTALLER'S NAME&PHONE NO!
SEPTIC TANK CAPACITY f Sw c a!
N r
LEACHING FACILITY:(type) - Soy 4"/ (size) So.k I
NO.OF BEDROOMS 23"
13UEWER OR OWNER
PERM 7`DATE: glld W COMPLIANCE DATE: I I)VI VO
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 fat of leaching facility) Feet
Furnished by
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v 0 ZkL
3 w 3
I?I'c' 71'I t 3'
https://www.townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar-016033&seq=1 1/2
9/4/2020 Assessing As-Built Cards
https://www.townofbarnstable.us/Departments/Assessing/Property_yalues/HMdisplay.asp?mappar=016033&seq=1 2/2
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Peppercorn Ln.
Property Address
Gale
Owner Owners Name
information is
required for every COtuit MA 02635 9/1/20
page. Citylrown 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: >120"
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: 2000 NGW 120"
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain: x
4'seperation per 2000 compliance on file
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain: -
TOPO mapping shows the site at 14'msl and nearby surface water at 2'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 121 Peppercorn Ln.
Property Address
Gale
Owner Owner's Name
information is
required for every Cotuit MA 02635 9/1/20
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:
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
rY
3
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OFF BARNSTABLE LOCATION t2' SEWAGE # 5"� /�/
—2049
VILLAGE--- ��`GI�7 ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. /
SEPTIC TANK CAPACITY SO1J ei a
LEACHING FAClLrrY: (type) - S oU 9B/CA!wl �(size) 50 1 5r
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: q 1 fYJ yv 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
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No. � �7y FEE /�r
Board of Health, / J A I W S A d�46:,MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(trlepair( ) Upgrade( ) Abandon( ) - Complete System ❑Individual Components
Location a i P 6 P iFKC-0&AJ Z-A P 67 Owner's Name zee t46;7 z tq) 6
Map/Parcel# I G Address
Lot# 3 3 Telephone#
Installer's Nam G.X=F-0L a U? Cu NJ-5.1— Designer's Name i'91Nkee. S u ,ve Cu-ISu(. t4 p7S
~ Address !'s-��D� 1 Address 4/0 (3 T"buifw
Telephone# - -7-1 Telephone# /a 6-00'SS .
S��0� S 7 s
Type of Building Lot Size / q.ft.
Dwelling-No.of Bedrooms Garbage grind®
Other-Type of Building No.of persons Showers ( ),Cafeteria( )
Other Fixtures
Design Flow(min.required) 50TO gpd Calculated design flow Design flow provided gPd
Plan: Date S7- /9- ®C> Number of sheets ;11 Revision Date
Title S [le i 5-P- (A� tf P
Description of Soil(s) l
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agr o install the ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o place in until a Certificate of Compliance has been issued by the Board of Health.
Signed --- _ Date
.� 3
No.,2V ,�i-s?�L� a FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, A f�N STt4 UJL-� MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit o�Constructo RepairOUpgradeOAbandonO - ®'Complete System ❑Individual Components
Location I ok I c=RC 0&AJ L/4 JUE Owner's Name Le-e t tr,f P91"C 6
Mapl/Parcel# G z Address
Lot#`, 3 3 Telephone#
Installer's Name' G -. N�-� Designer's Name yj90-k'Pe S U,'Ve V Q0,1SUC-tL4 ,V S
t
a Address yy�-�Dd,ST!'ti)l yla ,1 t L Address L/O -1 tn�uS�r �o,�l /D11�QS � /� S
Telephone# F -7-7 1 g Q Telephone# 4�A 6?-OO S57
Type of Building Lot Size /U-71 7 S sq.ft.
Dwelling-No.of Bedrooms Garbage grinp
Other-Type of Building No.of persons Showers ( ),Cafeteria( )
Other Fixtures
Design Flow (min.required) #411110M 6 50 gpd Calculated designflow � V Design flow provided gpd
Plan: Date S— _ O d Number of sheets Revision Date
Title
Description of Soil(s) 8
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned a to ins a ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t to place th men efadeauhtil a Certificate of Compliance has been issued by the Board of Health.
Signed Date �DO
1
Al
�� -spy r No COMMONWEALTH Of �'ASSAC14USETTS FEE �
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Board of Health, (ill t^-1 -6 I-e ' , MA. �
CERTIFICATE Of COMPLIANCE 6,
Description of Work: ❑Individual Component(s) ErComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructedt*(�,Repaired ( ),Upgraded ( ),Abandoned ( )
by: o M—v tj pm C li C;T1 u'J
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) approved d sin Tans/as built plans relating to
application No. dated Approved Design Flower ..�(gpd) e r
Installer / /,, /��.jn ( fin/ c'' _C A ( � 1
Designer:Yy9/yk-et ✓yn- eallm-T19/V nspecto, 1!'/A//f(� !!_ -A'1 J� A11hAfD toi? I ! ov
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. Z GCJ� S-7
FEE
COMMONWEALTH OF MASSAC14USETTS
r
Board of Health, VL S�`� if ' MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT '
Permission is hereby granted to; Construct(< Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at t o P E pp e R c-o R N LA V as described in the application for
Disposal System Construction Permit No.c %, dated Z� b
Provided: Construction shall be completed withinthree years of the date of this permit. A1.?7Poo/al conditio ss/mmu/st(y\�be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston MA Date q/Z � 1 Board of Health
s
TOWN OF BARNSTABLE
LOCATION � ����� r �'� , SEWAGE # � "Z �
VILLAGE C/� y7d�T ASSESSOR'S MAP & LOT — J
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ! slXJ y
LEACHING FACILITY: (type) - �- Sop yel Ceir k t,:((size) SO.S,- �.
NO.OF BEDROOMS _5
j BUILDER OR.OWNER GA/,11,
PERMTTDATE: q.11000 COMPLIANCE DATE:
i
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
j 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
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A RESIDENCE FOR THE
FAMILY OF ELAINE
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NOT RELEASED FOR CONSTRUCTION
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TOWN WATER AVAILABLE COTUIT
I BENCHMARK AS/LOT 32 LEGEND.
TACBOLT ON HYDRANT EXISTING CONTOURS - — 99
I — ELEVATION= 100.0(ASSUMED) PROPOSED CONTOURS
1 t�j cfl — 392.07'j,
►� q� cp �O 382.07' MAIN
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100 0•
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9 28.2' 20'
8 0'. 0 0 0 0 ,�4 100 LOCUS MAP
W 4 ° o .� ° \�
194.0' o ASSESSORS MAP. 16, LOT 33
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9 5' PLAN REF 16194 M, LOT 24
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w / _ 4 0, s \ ZONING.• „RF"
5 B v�O�° ' 0 VERLA Y DISTRICT "AP
HOUS �•
/ \ FLOOD ZONES: "C" & »B
�O\ 4 PROPOSED / 10.0' T.OF.. _ COMMUNITY PANEL f
V ASPHALT DRIVEWAY 1 I - 100.5 8.O' �. 250001 0022 D
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DATED: 7102192
54.°' `' o -SITE AND SEWAGE PLAN
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AS/LOT �33 BARNSTABLE, MASS.
PREPARED FOR.
AREA= 107575fSQFT. � -
g7 / LEE AND ELAINE GALE
90 `�4 REVISED. SEPTEMBER 21, 2000
F q
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wr# NKEE SURVEY CONSUL TAN TS
N85;24-00"Jr
P. O. BOX 265
400. 74' it : UNIT 5, 40B INDUSTRY ROAD
:ate
MARSTONS MILLS, MA. 02648
GRAPHIC SCALE PH.(508)428-0055 — FAX(508)420-5553
40 „lts• '
0 20 40 80 160 G ry'
V:lz' I
AS/LOT 34
m
( IN FEET ) ✓08 NO 52349 SHEET, 1 OF 2
1 inch = 40 ft. ,` C�r yY ..1..
a
100.5'
719P OF FOUNDATION
20 MIN.
10' MIN. CONCRETE COVERS 4" SCHEDULE 40 P. VC
j MIN. PI7CH 118 PER FT.E =99 2 LA YER OF
L "
1/8"-112"
CONCRETE COVER
♦ / / " MAX . EL=99.0 WASHEDS710NE
4" CAST IRON PIPE
(OR EQUAL MINIMUM
PI7rH 114 PER FT. k RISER CLEAN SAND 9
FLO W LINE MIN
INVERT 1 10"" EL=97.0
MIN. rlN
�2.0 ° °° o 0 0 0 0 0 0 0° -°EL.=_98 -_ CAST , LEVEL ° NBAFF6" SUMP ° ° o 0 0 0 0 0 0 ° °INVERT .5 IN INVERT ° ° ; ° ° ° EL._-`—
EL.=97 75' F EL.= 97 25_ EL.=97--- 4" 4"
INVERT
(To BE PLACED ON FIRM BASE) DISTRIBUTION EL.=R6.5"_ (5) 500 gal LEACHING CHANGERS
MECHANICALLY COMPACTED OR 6" OF SYONE BOX
1500 __GALLONS TO BE WATER TESTED h
IF MORE THAN ONE OUTLET - 50.5' X 12.8' TRENCH FORMATION
SEPTIC TANK PLACE ON s" STONE
314" M 1-112" SOIL ABSORPTION
DOUBLE WASHED SMNESYSTEM (SAS
PROFILE OF
SEWAGE DISPOSAL SYSTEM *� NO WATER ENCOUNTERED BOTTOM OF TEST HOLE ELEV.__ 88 _
OBSERVATION HOLE I ELEV.=_ 98' _
NOT TO SCALE PERCOLATION RATE G_2__ MIN./ INCH (9 48" OBSERVATION HOLE 2 ELEV.__ 98'_
DEPTH HORIZ TEXTURE COLOR M07T. OTHER DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
0-12" A TOPSOIL 0-12" A TOPSOIL
12"-36" B MEDIUM TO 12"-36" B MEDIUM TO
COARSE SAND COARSE SAND
GENERAL NOTES 136"-120't C IFINE WHITE SANDI PERK 36"-120 C FINE WHITE SAN
NO WATER ENCOUNTERED NO WATER ENCOUNTERED
1) ALL WORKMANSHIP AND MA TERIALS SHALL CONFORM TO D.E.P. P 815
TITLE 5 AND THE TOWN OF _BARN,SL9RLE____ RULES AND
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE.
2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO SOIL TEST
WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" DATE OF SOIL TEST 10/22/81 SOIL TEST DONE BY CAPE & ISLANDS SURVEYING CO.INC.
3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN WITNESSED BY: JOHN JACOBI
10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE DESIGN CAL CULA TIONS:
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. NUMBER OF BEDROOMS . . 5
4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL r GARBAGE DISPOSAL . . . . . . . . . NO
BE MORTERED IN PLACE. Ir. TOTAL ESTIMATED FLOW
5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH ( RQ_-GAL/BR/DA Y x 5 BR.) 550 GAL/DA Y
DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO INSTALL FIVE' (5) ACME REQUIRED SEPTIC TANK CAPACITY 1500 GAL
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 500 GALLON LEACHING CHAMBERS
6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VA TION CONTRACTOR SOIL CLASSIFICA TION . . . 1
� IS TO CALL "DIG— SAFE" AT 1-800-322—4844 AT LEAST 72 HOURS 4 FEET OF DOUBLE WASHED STONE DESIGN PERCOLATION RATE . . . . . < 2 MIN./IN.
PRIOR TO COMMENCING WORK ON SITE. SIDES AND ENDS EFFLUENT LOADING RATE . . . . . . 74 GAL/DA Y/S.F
7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS 50.5' X 12.8'1 LEACHING CAPACITY (AREA X RATE) 665 GAL/DAY
SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. RESERVE LEACHING CAPACITY . . 665 GAL/DAY
8) PARCEL IS IN FLOOD ZONE___"C" & "B" . (50.5 X 12,8 X . 74)+(50.5+50.5+L2.8+L2 8 X . 74 X 2)
9) LOT IS SHOWN ON ASSESSORS MAP __IB AS PARCEL
{
SHEET 2 of 2 JOB NUMBER__ 52349 ______
1