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HomeMy WebLinkAbout0533 POPONESSETT ROAD - Health 533 POPONESSETT ;r�i A 006 062 _ f UPC 10334 61L -F°'' r i I McKenzie, Marybeth From: McKenzie, Marybeth Sent: Thursday, March 25, 2021 4:25 PM To: McKean,Thomas Subject: RE: 533 Popponesset, Cotuit Thank you. Mb From: McKean, Thomas Sent: Thursday, March 25, 2021 2:59 PM To: McKenzie, Marybeth Subject: RE: 533 Popponesset, Cotuit Yes have no objections From: McKenzie, Marybeth Sent: Thursday, March 25, 2021 2:10 PM - To: McKean,Thomas Subject: 533 Popponesset, Cotuit HI Tom, This guy is trying to close the sale on his house on Monday and the Inspection report just came in: Before you left for vaca-1 don't know if you remember the address, but 533 Popponesset was looking for 4 bedroom, but their permit was for a 3 bedroom design.Then years ago it got a sign off for the 4th bedroom.So you said to have them do a Title V inspection which they did, but the design flow was left as n/a because there wasn't anything on file (which there was), but they made note that they had 2-6' x 8' pits both connected to the dbox. I know that size can accommodate 4 bedroom. Would that suffice to allow them the 4 bedrooms. Marybeth McKenzie R. S. Health Inspector Town of Barnstable (508) 862-4644 J Assessor's office (1st floor): Assessor's map and lot number of tN¢�o` Board of Health (3rd floor): ') Sewage Permit number ®!� P�'J� CH•R(, yb� � �fio> -& Tait �N��( M . ............. Z EAUSTME. i Engineering Department (3rd floor); `�i ;� gEpnC g ANUS rb 9 \ems House number .......... t-J IN COMPLIe: Definitive Plan Approved by Planning Board ________________________________19-------- . APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TITLE Etc �"�T C®C� : :_�•.°� TOWN OF BARNS ci TioN1 BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... `' .`� p �1 .S �7..................................... ........................................... TYPEOF CONSTRUCTION .................. . ................................................................................................... 3 G TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .......... .......: ........................................................�..c?..�... ...................................................... 4 ProposedUse ............................ '..:`1.f4:. J..C.. `:...............J...�-/ ......................................................................................... Zoning District � �J� ` 7 .........Fire District C.f.e. �' Name of Owner ......f:n........./. r-..�..`... Address .... �,,�.. 3........I r'. .:� '.��.. .':S.....'..... at..�'.... i Name of Builder ......0.L................:......'..'..`........................Address .......... . ..r?.G. .... ,%.Pit.r:.A*..rk..............."n.A......... Nameof Architect ............... .�! c' �' Address.............................................. .................................................................................... Number of Rooms ........................................Foundation ................... G..`..`. .......................... ......................................... Exier for `.... <-'c:............ ............Roofing ........... .................................. Floors �'1..... ... a .................Interior c` t...............................................:.................................... Heating ................................................................ Plumbing................ . .................................................................................. Fireplace ...............Approximate Cost .................../......70 Zt <y z Area Diagram of Lot and Building with Dimensions Fee. ............................................. 1 ra*, L2 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. . clL. Construction Supervisor's License .................................... L Assessor's office (1st floor): /j !J " DDT OF TNE'TO Assessor's map and lot number .............................R �/�ou�^S � Board of Health (3rd floor): Sewage Permit number ®� PE A Cq o To F� m' , M ...•........................... ............... Z 9AMISTAELE. i Engineering Department (3rd floor): ��3 r'� SEPTIC SYSM MU ,"a39 House number .......... �-/ In COMPL.k :; Definitive Plan Approved by Planning Board ________________________________19__-- TITLE 5 APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only E Y LIT CODE TOWN OF BARNS r �Tioas BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... .:............:....................................................... ..'....................................... TYPE OF CONSTRUCTION .. .................................................. ................................. .............. .................................19...v J TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........ .-).................................................................!. ........................ ...... ?..:.............ct?.. ...L:..:...!....................... r ..........:��... ... � Proposed Use ............................ .. 1.�S:..C-1..s..!^:..... .................................................................................... ID Zoning District .......:...................... .......................................Fire District i `s ......................... .................................................... Name of Owner �% :� 2 r�.. /.......f ' �_c v J..3........v. f ;- A` ? i �.^. ....�`.as ..:...... ........Address .... ! c Address ( .J.G. ..... %.a.r:.�'..ti..:.........'. Name of Builder .... .i. .!...:.........Z.......................... .......... . .pn.A-........ Name of Architect c' i' ..Address Number of Rooms ...Foundation ...................t?..i-G ...``--i............................................................... .................................. Exterior `� Y L' r'.. ...................................Roofing ............ �1 .. 'i .{...! Floors I...........................Interior L,_1 r' Heating ..................................................................................Plumbing .................................................................................. Fireplace ............................................Approximate Cost ...................`.'..:7c......'...F:.......................... ..................................... Area Diagram of Lot and Building with Dimensions Fee OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. cx Name ...........Vj-.,u �— Construction Supervisor's License ........................:........... PIERCE, GARY F. No „ 32043 Permit for ..Build Garden Shed AccessorX to Dwelling Location ..... 33...Popponess.ett. ....Road..... .... ......... Cotuit Owner Garry F... Pierce .............. . .......................... Type of Construction ......Frame ............................................................................... Plot ............................. Lot .................................. Permit Granted .....JulY...5.r.................19 88 Date of Inspection ................ 19 Date Completed ................ ... ...........19 r� a 5 6 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma Parcel o�. �JES . S J P � �_ 'Permit# 3cn - Health Division � Xx i %rYL i..l _ c' Da7lsqd_p Conservation Division ,,ri q e � R TaxCollector ` Treasurer. Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address f 33 /co Village 6)61U 'T Owner _od-'vF_ JR,,L& AA;oFf,zsck1:RiCH1ggo a" ddress 533 'Po 12pc►yC-- 3r rT fro- TelephonePermit Request_ nop CY AR.+oar l i4M� l.N �hc���9 ADDi 14gIL1� Square feet: 1st floor: existing proposed y8Y 2nd floor: existing proposed Total new Estimated Project Cost 3�4,Crc, Zoning District Flood Plain Groundwater Overlay Construction TypeFi C, r406- Lot Size AC(,1f s V/,z Grandfathered: ❑Yes O No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: 0 Yes f"No On Old King's Highway: ❑Yes M No Basement Type: dFull ❑Crawl YWalkout' ❑Other Basement Finished Area(sq.ft.) -0 Basement Unfinished Area(sq.ft) Number of Baths: Full: existing / new ! Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths : existing' '7 new I First Floor Room Count 5� Heat Type and Fuel: ❑Gas @(Oil ❑ Electric ❑Other Central Air: ❑Yes No Fireplaces: Existing New t Iry Existing wood/coal stove: 0 Yes 2�No Detached garage:0 existing ❑new size Pool:0 existing ❑new size Barn:0 existing ❑new size Attached garage:9 existing Lew size Shed:©existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes M(No If yes,site plan review# Current Use 5 &k"/`-- crrn,iy Gn1 Proposed Use BUILDER INFORMATION Name_ '��c f/iir'y ;,�r?`� ,�,�'': Telephone Number Address .; "� /�"c �t�c�1/c, .s r- 1-'"L` Rd, License# Cd Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE '� / v ,,, �' DATE _ /10;,�,E/I���r .3,19f9 EngineeriLDpt. d floor) Map �� Parcel �6 2a&( ermit#House# — Date IssuedBoard o Hfloor)(8:15 -9;30/1:00-4:3 ) � Awls � C ee C90 pt,..,� .� n ic..hnnl IH! r 19 • RARN51'9. JA >> TOWN OF BARNSTABLE • Building Permit Application Project Street Address I P e©ri g s s ,6 r 7— cp A a Village 1. 1 V % T n Owner �/�f? fl v Y' O_C, Address Jrj 3 �o a P©ti C-SS i, Telephone , - to 3 Z - n 141.y r T� 'F Permit Request ;� M o a 1<2 'T t. J,I f n) '�—' A 74 +c�> First Floor square feet Second Floor square feet Construction Type p Estimated Project Cost $ 0012 Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count 1-feat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name d Telephone Number/ /7/.3 Ad ress 7 CU License# Q ''f 7 .� Home Improvement Contractor# /1/(r9 9& Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DE$RIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO yF SIGNATURE - DATE BUILDING PERMIT D NIED FO, E WLOWING REASON(S) \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce r Owner Owner's Na�}� information is Cotuit �/ Ma 02635 3-11-2021 required for every rw page. City/Town ! State Zip Code Date of Inspection I 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 a filling out forms A. Inspector Information SI f° ISoZ on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 as Company Address Sandwich Ma 02563 City/Town State Zip Code rat» (508)477-0653 S113747 Telephone Number License Number i 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 I 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails I t i Brett Hicke Digitally signed by Brett Hickey Y Data:2021.03.1207:51:29-05101 3-11-2021 Inspector's Signature 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. I 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every 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 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System consists of a 1500 gallon septic tank, d-box and 2 cesspools. Components were all in passing condition. 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 Commonwealth of Massachusetts - Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma" 02635 3-11-2021 required for every page. City/Town State Zip Cade 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every page. City/Town 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 ❑ o Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ El due 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 I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every St page. City/Town ate Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool . ❑ Q Liquid depth in cesspool is less than 6"below invert or available volume is less than 1Y2 day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El 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. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ D 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every page. City/Town State Zip Cade 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 El ❑ 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? El ❑ 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? E] ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ [j] Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? o ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? ❑ El 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: El ❑ Existing information. For example,a plan at the Board of Health. El ❑ 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)] 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 n Commonwealth of Massachusetts + _-- Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans 4 Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA Description: No design plans or permits were on file with Board of Health 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes [j] No Does residence have a water treatment unit? ❑ Yes of 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 0 No Seasonal use? ❑ Yes ❑. No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2020- 88,000gallons 2019- 123,000gallons Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is cotuit Ma 02635 3-11-2021 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): r 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: Owner- last pumped 1 year ago Was system pumped as part of the inspection? ❑■ Yes ❑ No If yes, volume pumped: 1500gallons How was quantity pumped determined? tank size Reason for pumping: maintenance after inspection t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every page. City/Town Satet Zip Cade Date of Inspection D. System Information (cont.) 4. Type of System: El 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: Unknown due to lack of record Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): 1'6" Depth below grade: feet Material of construction: ❑cast iron ❑■ 40 PVC ❑other(explain): Distance from private water supply well or suction line: Town waterfeet 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 Commonwealth of Massachusetts - - , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 611 Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: 1500gallons 611 Sludge depth: 30" Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1411 Distance from bottom of scum to bottom of outlet tee or baffle 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.): The tank was in working order at the time of inspection. The tank was pumped after inspection for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts ------------ - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth&Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every St page. Citylrown ate Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts _- = Title 5 Official Inspection Form - !1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ( .�l° 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): NA *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: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: El overflow cesspool. number: (2) 6'x8' ❑ 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 533 Popponesset Road Property Address David Pierce Owner Owners Name information is Cotuit Ma 02635 3-11-2021 required for every 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.): The SAS consists of 2 over flow cesspools. Both are made of blocks are were dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration SEE ABOVE 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.): t5ins .doc•rev.7/26/2018 Title 5 Official Inspection Form:P p Subsurface •Sewage Disposal System Page 14 of 18 P Y 9 Commonwealth of Massachusetts ------------ :_= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA 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 Ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form ,Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for ever y 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 533 P Opp onesW Road cotutt 3 O 1 . Garage: Ddveway Garage Drivemy 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 ,- i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is cotuit Ma 02635 3-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑0 Check Slope ❑■ Surface water FBI Check cellar ❑® Shallow wells Estimated depth to high ground water: No GW 3' below SASfeet 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 0 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: A hand hole was augured to determine high groundwater. Hole was augured >3' below SAS and no water was encountered. r s Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I # • r Commonwealth of Massachusetts g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 533 Popponesset Road Property Address David Pierce Owner Owner's Name information is Cotuit Ma 02635 3-11-2021 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑E 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No. `� O T Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes RpPlitation for ]Disposal 6pstem Construction permit Application for a Permit to Construct( )' Repair/Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No-T,33 hpane- -�P.Jp ner's game,Address,and Tel.No. Assessor's Map/Parcel .(jp(, Installer's Name,Address,and Tel.Not 4- -0711-93 9 Designer's N e,Address,and Tel.No. Type of Buildin . 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) 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 Environments d not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal SigneA Date /,9 r S Application Approved by Date Application Disapproved by Date for the following reasons Permit No. al)o{J ""'0�_ D-) Date Issued S c` Fee ! 0V TH 6OMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon(d) [:]Complete System M<dividual Components f _ Location Address or Lot No.s'33 y6 tw6 6 PGd 0 ner's Name,Address,and Tel.No. Co+u i !/Cc vc� vc� p.o +6k/G.S" Assessor'sMap/Parcel UO(o O& 0ae S.-. Installer's Name,Address,and Tel.No.,50-,5-'77 ` 3 S'9 Designer's N/ne,Address,and Tel.No. / 00r-�,,�b CbY1S'E Y CIC�r t G(/��M#NC_ `�,C 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) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal systenV in accordance with the provisions of Title 5 of the Environm _Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health!' SigneLr_.. c Date /S Application Approved by _ Date Application Disapproved by Date for the following reasons Permit No. C'�o 1✓� `© �'"+ Date Issued G} --------------------------------------------------------------------------------------------------------------------------------------- X THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by at 533Own No. c_'oy�j has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No-, -)-e7 dated 4/( q �� Installer odr�o/ �� /cam. Designer ►D 1 ,x v }t #bedrooms Approved d9 9 t flow gpd The issuanc of his pet its l not be construed as a guarantee that the system vl it �ti designed c Date Inspector ----- J ---------------------------_ ---------------------------------------------------------------------------- a l o Fee _ V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair / Upgrade( ) Abandon( ) System located at.,,,j 3 3 J ol)onC SSfE-f -- &d 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 in t b crfleted within three years of the date of this pe it. Date L/1 Approved by Commonwealth of Massachusetts '``` . Title 5 Official Inspection Fora _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 533 Popvonessett Road�M Property Address r;+ David Pierce Owner Owner's Name ::tt information is Cotuit MA 02635 4/3/15 �a. required for every -- 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, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return key. Name of Inspector r DiBuono Sewer and Drain j rea Company Name 8 Johns path Company Address �r S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 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 ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/3/15 _ In ector's Signature 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 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: The system contains a 1,500 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is rotted and in need of replacement. The leaching is made up of two 8ft by 5 ft Cesspools both in working condition. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 533 PoPp onessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 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): System passes as long as Dbox is replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the'Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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 (Sins•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 ��M ,• 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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 '/z day flow t5ins•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 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 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 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 thq' system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department: t5ins•3/13 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 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 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? E] ® 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: ZI ❑ 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 be (actual): 4 — 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 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1,500 gallon tank as well'as a concrete Distribution box. All tees and baffles are in place. The Distribution box is rotted and in need of replacement. The leaching is made up of two 8ft by 5 ft Cesspoolsboth in working condition. Number of current residents: 2 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 ears usage d 2013 12,000 g ( y g (gp )) 2014 30,000 Detail: 57.7 GPD Sump pump? ❑ Yes ® No Last date of occupancy: Occupied 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 ❑ to 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 Commonwealth of Massachusetts Title 5 Officia-I Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'' 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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 0 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 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: Tank is approximately 17 years old. cesspools are approximately 40+ years old Were sewage odors detected when arriving at the site? - ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18 "s 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.): System is vented throught the roof Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,500 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gallon Sludge depth: 311s — t5ins-3113 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 w„ 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 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 24 s Scum thickness 3"s Distance from top of scum to top of outlet tee or baffle 42"s Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick How were dimensions determined? Tape 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.): Tank was pumped in 2011 Grease Trap (locate on site plan): Depth below grade: NA _ 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 s --------- Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•�113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 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.): No evidence of leaking. Pumping is recommended 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '�M ,•'� 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Needs to be replaced 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.): Distribution Box is in need of replacement i 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form: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 ;M 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching,galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool number: 2 ❑ 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.): No signs of carry over. no signs of hydrualic failure 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 (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 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.): No signs of ponding or hydrualic failure. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 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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+ ft 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: usgs map You must describe how you established the high ground water elevation: Property sits 20 ft above nearest water venue. According to usgs maps system is approximately 30 + ft above ground water. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M ,•''y 533 Popponessett Road Property Address David Pierce Owner Owner's Name information is required for every Cotuit MA 02635 4/3/15 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARWWLE LOCATION %o O• SEWAGE M ^1'3 VILLAGE SESSOR'S MAP&LOTJ't7tS+'O�z INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY_ �� Q Oct— LEACHING FACILITY:(type) 6 l`r!i!`�C. (size) NO.OF BEDROOMS BUILDER OR OWNER PERMrrDATE: I " �/� %L� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet�of�+hing facility) Feet Furnished by i47-.*'d A459/1,," Ell n � � .. -Z http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=006062&seq=1 4/9/2015 9 f0 IVE� _ av MAY 1 8 1999 ` TOWNOFggq 0 H�iunRn ti 9V� lJ -A TH OF MASSACHUSETTS EXEC IVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 533 POPONESSETT, l D.�MAP�006 PAR 062 Name of Owner GARRY F.PIERCE (� Address of Owner: BOX 770 COTUIT MA.02636 Date of Inspection: 6/12/99 Name of Inspector:(Please Print)JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: nla Mailing Address: n/a Telephone Number: nla CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpectlon is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evaluati By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not Imply any warranty or guarantee of the longgevity,of the septic system and any of its components useful life. Inspector's Signature: ) Date:6/14/99 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 633 POPONESSETT RD.MAP 008 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:6/12/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: Wa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced nta The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is removed revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 633 POPONESSETT RD.MAP 006 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:6/12/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n!a- (approximation not valid). 3) OTHER nLa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 633 POPONESSETT RD.MAP 006 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:6/12/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 633 POPONESSETT RD.MAP 006 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:5/12/99 Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 633 POPONESSETT RD.MAP 006 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:6/12/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):3. Total DESIGN flow: = Number of current residents:i Garbage grinder(yes or no):MQ Laundry(separate system)(yes or no): MQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): Iva Sump Pump(yes or no): NO Last date of occupancy: n& CO M M ERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: nLa gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:nLa Last date of occupancy: nta OTHER: (Describe) n& Last date of occupancy: Wit GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):MQ If yes,volume pumped Wit- gallons Reason for pumping: Wit TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: Wit APPROXIMATE AGE of all components,date installed(if known)and source of information: CESSPOOLS ARE ORIGINAL WITH NEW TANK IN 1996 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 633 POPONESSETT RD.MAP 006 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:6/12/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 14" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: WA Comments: (condition of joints,venting,evidence of leakage,etc.) nLA SEPTIC TANK: X (locate on site plan) Depth below grade: K Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) ILA If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ Wa Dimensions: L 10'6"H 6'7"W 6'R" Sludge depth: 1"" Distance from top of sludge to bottom of outlet tee or baffle: 3E Scum thickness: 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: 1Z How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC:TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nta Dimensions: ILA Scum thickness: ILA Distance from top of scum to top of outlet tee or baffle:_DLa Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) ILa revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 633 POPONESSETT RD.MAP 006 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:6/12/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nta Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) II& Dimensions: n& Capacity: nLa gallons Design flow: nLa gallons/day Alarm present: XG Alarm level:.i1a- Alarm in working order:Yes—No—: NQ Date of previous pumping: Wit Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION('continued) Property Address: 633 POPONESSETT RD.MAP 006 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:5/12/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) -If not located,explain: n1A Type: leaching pits,number: Wa leaching chambers,number: j leaching galleries,number: _nLa leaching trenches,number,length: nLa leaching fields,number,dimensions: Wa overflow cesspool,number: 2-628'BLOCK PITS Alternative system: Wa Name of Technology: _iVa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE OVERFLOWS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY ONE PIT WAS EMPTY ONE PIT HAD 6'IN IT. CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:nta Dimensions:n(a Depth of solids: Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 633 POPONESSETT RD.MAP 006 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:6112/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a E A 0 jo 01 o 0 AA yo AC A 5'7 V-7 y� revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 633 POPONESSETT RD.MAP 006 PAR 062 Owner: GARRY F.PIERCE Date of Inspection:6/12/99 NRCS Report name: WA Soil Type: n(a Typical depth to groundwater: nla USGS Date website visited: n(a Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL revised 9/2/98 Page 11 of 11 TOWN OF B ABLE LOCATION 3%P(X. O SEWAGE # VILLAGE .--ASSESSOR'S MAP&LOT 'l��' �� INSTALLER'S NAME&PHONE NO �� co �I SEPTIC TANK CAPACITY LEACHING FACILITY: (type) -(ZX U (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE-7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet ofknhing facility) Feet Furnished by -710 /4$$/V ' 0, Bz qG 7 -D� � F - wl �.L C� 3 Af- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS e ZIppYication for 30igpogal *pztent n�truction permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: 7 Location Add ss�or Lot No�y1 Owner's Name,Ad s d el.No. 3 f � — C�L� Assessor's Map/Parcel onco �1 ^� Installer's Name Address,and Tel.No. 3a2 Designer's Name,Address and Tel.No. I M 00,A Type of Building: Dwelling No.of Bedrooms _ Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Na re of Repairs or ations(Answer wheg applicable) v I� 5 .- 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 provision&of Title 5 of the Environmental Code and not to place the system in operation u til a Certifi- cate of Compliance has been 'ssued y is Bo �ftl . Signed Date Application Approved by d Date Application Disapproved for the following reasons Permit No. "'� Date Issued ————————————————————————————-—————————— �� w A ,: ' _/ - /`, Fee �r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLEs MASSACHUSETTS 2pplicatton for Diopooal *pgtem maruction Permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: i Location Address or Lot No r- � u1V C � y� Owner's Name,]Ad s d Thl.No: Assessor's Map/Parcel Coca O�OR Installer's Name,Address,and Tel.No: J'{0'2.?% Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alt rations(Answer when applicable) W1 , . L_r 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 provis iqAsof Title 5 of the Environmental Code and not to place the system in operation u til a Certifi- cate of Compliance has been S;;ed y s Bo of the Signed I1 n Date Q 3 Application Approved by '� i d / Date Application Disapproved for the following reasons , X�7 Permit No. "' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Dispp.4 Systemirmt4d( )or repaired/replaced( on by Instal at hp.s(been constructed in accordance' with the provisions of Title 5 and-the for Disposal System Constructio rmit No. �'''f' fed Date Inspec'to THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT T E SYS- TEM WILL FUNCTION SATISFACTORY. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Mir ssar �!5tem Construction 3permit Permission is hereby granted to to onstruct( )/reep�pa_�ir( �On-site Sewage System located at No.# UVII\ Street and as described in the above Application for Disposal System Construction Permit. No. t Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special cBnditions. j All construction must b 7co &6jetedithin three years of the date below. ADate: Approved by i ,' ��' 4 d Board of H? /vj CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONS'FRUC71ON I'EliMl'l' (�Vt'1'IIOU'I'DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated ) 9 -�' concerning the property located at6-'O' �' eets all of the following criteria: , _ ' •' %: • There are no wetlands within 300 feet of the proposed septic system l' • There are no private wells within 150 feet of the proposed.septic system •" • The observed groundwater table is 14 feet or greater belowthfe bottom of the leaching facility • There is no increase in flow and/or change in use proposed • . • There are no variances requested or needed. SIGNED DATE. 3/No LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAtlach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, (his plan should be submitted]. � (�- ��j '�,_" ��� t \� ' v � � _ ! ' ,' 'Z.�" 0 V �, TpwN OF BAR*S�ABLE # a - 3 d Q SEWAGE 4�, SSESSOR LOC O 'S MAP LOTO. �ZZ4 ATIN _ VILLAGE INSTALLER'S NAME&PHONE NO SEPTIC TANK CAPACITY �. (size) LEACIOG FACILITY.' (ty NO.OF BEDROOMS rw ` DER OR OWNER OMP LIANCE DATE: `� BUII. Cr. A'TE: t TERMITI Fee ce Between fie' aching Facility Separation Distan Feet Adjusted Groundwater Table and Bottom of wells exist Maximum 1 Well and Leaching Facility (E private Water Supp y feet of leaching facility) Feet on site or within 200 Facility(If any wetlands exist Edge of Wetland and Leaching feet o����ng facility)� A , within 300 /v Furnished by V