HomeMy WebLinkAbout0562 POPONESSETT ROAD - Health -562 Poponessett,Road.
Cotuit
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/ TOWN OF BARNSTABLE1
LOCATION S(� EV OAVV 55 t/7" /2 SEWAGE #
VILLAGE C'd-f,-,U r ASSESSOR'S MAP & LOT
a)5/►fc Gi@S 1�iJ P/ Al
S NAME&PHONE NO.
SEPTIC TANK CAPACITY S £ 71'L /iy SP g.C Z/a iy
LEACHING FACILITY: (type) (size)
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'-BU LDER.OR'OWNTER �'�� , /�w�' �x C F
P ERMITDATEf
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A: Sep.aratioi Distance Between the:
.F'Maximuin Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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COMMONWEALTH OF MASSACHUSETTS
z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
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350 MAIN STREET
WEST YARMOUTH,MA
508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 007 PAR 004-001
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner's Name: GORE, LAWRENCE
Owner's Address: 562 POPONESSETT ROAD RECEIVE[)
COTUIT,MA 02635 E"
Date of Inspection AUGUST 19,2003 c C
Name of Inspector:(please print) JAMES D.SEARS SEP 0 5 2003
Company Name: A&B Canco TOWN Or BARNSTABLE
Mailing Address: 350 Main Street HEALTH DEPT.
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systerns. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector.'s Signature: Date:
The system inspector shall su rnit 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 tot he buyer,if applicable,and the approving authority.
Notes and Comments
TANK AND COVERS ARE UNDER STONE WALKWAY.
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
r1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner: GORE, LAWRENCE
Date of Inspection: AUGUST 19,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: ✓
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner: GORE, LAWRENCE
Date of Inspection: AUGUST5 19,2003
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety,or the environment.
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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Foim 6/15/2000 3
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner: GORE,LAWRENCE
Date of Inspection: AUGUST 19,2003
D. System Failure Criteria applicable to all systems: N/A
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
J 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 leaching is less than 6"below invert or available volume is less than %2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of tirnes pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CM 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: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd.to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone 11 of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
r
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner: GORE,LAWRENCE
Date of Inspection: AUGUST 19,2003
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 nonnal 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
If 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)has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CM 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner: GORE,LAWRENCE
Date of Inspection: AUGUST 19,2003
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CM 15.203(for example: 1 10 gpd x#of bedrooms: 440
Number of current residents: 2
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2001 29,000/2002 106,000
Sump pump(yes or no) NO
Last date of occupancy: UNKNOWN
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
2001 PERMIT#2000-659
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner: GORE, LAWRENCE
Date of Inspection: AUGUST 19,2003
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 12"
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 16"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,500 GALLON PRE CAST
Sludge depth: I,,
Distance from top of sludge to the bottom of outlet tee or baffle: 29"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions detennined: ASBUILT,PLAN AND TAPE
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 AT WORKING LEVEL. INLET TEE,OUTLET TEE.TANK AND COVERS 16"BELOW GRADE.TANK
AND COVERS UNDER STONE WALKWAY.NO SIGN OF LEAKAGE OR OVERLOADING.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: _ concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
y ,
Title 5 Inspection Form 6/15/2000 7
G
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner: GORE, LAWRENCE
Date of Inspection: AUGUST 19,2003
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alann level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alann and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
DISTRIBUTION BOX IS 16"x 16",4'<4"BELOW GRADE.ONE LINE IN,TWO LINES OUT.BOX IS CLEAN
AND LEVEL.NO SIGN OF OVERLOADING OR SOLID CARRYOVER.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alanns in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner: GORE,LAWRENCE
Date of Inspection: AUGUST 19,2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
./ leaching chambers,number: 4
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS FOUR 500 GALLON CHAMBERS. LEACHING IS 4'10"BELOW GRADE. LEACHING IS
NEW AND DRY WITH 4' STONE.NO SIGN OF OVERLOADING OR SOLID CARRYOVER.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
P �
Paoe 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 562 POPONESSETT ROAD '
COTUIT, MA 02635
0
Owner: GORE, LAWRENCE
Date of Inspection: AUGUST 19,2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Title 5 Inspection Form 6/15/2000 10
Page 1 1 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 562 POPONESSETT ROAD
COTUIT,MA 02635
Owner: GORE, LAWRENCE
Date of Inspection: AUGUST 19,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 12 feet
Please indicate(check)all methods used to detennine the high ground water elevation:
_./ Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation 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:
a
You must describe how you established the high ground water elevation:
TEST HOLE ON PLAN. 12' NO WATER. BOTTOM OF LEACHING AROUND 7'.
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Title 5 Inspection Form 6/15/2000 1 I
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for Migpogaf. *pgtem Cottgtruction Vermtt
Application for a Permit to Construct(, Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components
Location Ad y` o /� Owner's Name,Address and Tel.No.
Assessor's 4t / �
ress
Installer's Name,Add ,an '( Designer's Name,ALdddress and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building S No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow U gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets L Revision Date
Title
Size of Septic Tank l SsG D Type of S.A.S. Sae-, C/ tis�
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) eLl S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issy9d by this Boar f Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No —6-S Date Issued �/ 3
TOWN OF BARNSTABLE -
LOCATIONS�
SEWAGE #
VILLAGEl y y 1 ASSESSOR'S MAP & LO got
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I INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
i (size)
LEACHING FACILITY: (type)
,.n nc AGr-)R(1O MS �1
l BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private.Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching.facility)
'
Edge of(;Wetland and Leaching Facility (If any wetlands exist Feet
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within,300 feet of leaching facility)
Furnished by
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No. —L�l.(4�� .,..x„'.�..*, .�.w,� Fee�—
y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Mioo!5al *raem Construction Permit
Application for a Permit to Construct(,- Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Ad sw^� aq� ��� Owner's Name,Address and Tel.No.
Assessor's aO��\� ��Q t 4 /)G
Installer's Name,Address,an Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 45_ No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flo4v. U gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets 2- Revision Date
Title t
Size of Septic Tank 1 S'"00 Type of S.A.S.
Description-,f Soil
Nature of Repairs or Alterations(Answer when applicable) I-,/ w ' 5 SK r.
Date last inspected:
J Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu by his Boar f Health.
Signed Date
Application Approved by Date Ttlriz-�
Application Disapproved for the following reasons
Permit No.Zdz-v -(o S Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site�}Serwage Disposal System Constructed( Repaired( )Upgraded( )
Abandoned( )by M I �� f r- `I 1 /
at .S6 Z f/*�s/P . ;(6.1e4" has been constructeo in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.'7i4D'�--4 S 9 dated // Z,a�
Installer Designer
The issuance of this permit shall not be constru If)
d as a guarantee that the system will function as d signedDate /1InspectorU_:' i./Yl / 1
---------------------------------------
No.-C,� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi5pogar *pgtem Conotruction Permit
Permission is hereby granted to Construct(`05 epair( )Upgrade ) andon( )
System located at 6 Z �a�� vuJJe ��
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and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this a It.
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Date: /�1 �/ � Approved by 4/ ��t �,
���O( 7/u/oI �,C
t. TOWN OF BARNSTABLE
LOCATION �a ,D rf 'rcf-'SEWAGE # 66
VILLAGE ASSESSOR'S MAP & LO tea.
• INSTALLER'S NAME&PHONE NO. A-"Li ke—,L°
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 00 6G L t (size)
NO,,OF BEDROOMS
BUILDER OR OWNER - .�.✓
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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TOWN OF B STABLE
LOCATIONS SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) - (size)
NO.OF BEDROOMS
BUILDER OR OWgg.R
PERMTTDATE: 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 Leac 'ng Facility(If any wetlands exist
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within 300 feet of ead g i ' ) Feet
Furnished by 6 =°
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COMMONWEALTH OF MASSACHUSETTS (/
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
z > DEPARTMENT OF ENVIRONMENTAL PROT i8
ONE WINTER STREET, BOSTON, MA 02108 617.292.5 f�
m c�ivEp
WILLIVA F.WELD JLI 1 'DY COXE
Governor 1 5 19 TO Sccretar\
ti
ARGEO PAUL CELLUCCI If4t NSTgg(f 97 D STRI'HS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO EPT ommissionci
PART A A •,`
CERTIFICATION
Property Address:562 Poponessett Road Cotuit MASAdress of Owner: E ti
Date of Inspection: 6/1 9/97 (If different)
Name of Inspector: Joseph P.Maeomber Jr.
I am a DFTP p ved system insrctpr pursyant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: " •-• aco leer CSC JOn 1nC
Mailing Address: Box Centerville ,Mass .. 02632
Telephone Number: 508-775-3338
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:
_L/Passes
_ Conditionally Passes
— Needs Further Evaluatio By the Local Approving Authority
Fails
Inspector's Signature: / �r Date: l 7
The System Inspector shall gi ibmit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY: Check A, B, C, or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
,Ld 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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/91) page 1 of 10
DEP on the World Wide Web: http:llwww.magnet.state.ma.us/dep
0 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 562 Poponessett Road Cotuit ,Mass .
Owner: David Carlson
Date of Inspection: 6/1 9/97
B) SYSTEM CONDITIONALLY PASSES (continued)
ti0 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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
A?,� The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
ill d 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
1) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) 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 to 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 (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 562 Poponessett Road Cotuit ,Mass .
Owner: David Carlson
Date of Inspection.6/19/97
D] SYSTEM FAILS:
You ust indicate ei;!:er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No/
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
O/ 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 inntthred istyibution box above outlet invert due to an overloaded or clogged SAS or cesspool.
/ le
ss Liquid depth in-eesspee4��is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
/ Number of times pumped _.
1V Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
ZI Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
41b . 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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
� e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 562 Poponessett Road Cotuit,Mass .
Owner: David Carlson
Date of Inspection: 6/1 9/97
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes N
Pumping information was provided by the owner, occupant, or Board of Health.
_ 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.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,.eluding the Soil Absorption System, have been located on the site.
_ 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.
J —The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) Pegs 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 562 Poponessett Road Cotuit,Mass .
Owner: David Carlson
Date of Inspection:6 9/9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow:Z.p.d./bedroorn for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):
Laundry connected to system (yes or no):Z—V--,
Seasonal use (yes or no): 5
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):
Last date of occupancy4a l
COMMERCIAUINDUSTRIAL:
Type of establishment:_ jt/I9-
Design flow: /J allons/day
Grease trap present: (yes or no)z�o
Industrial Waste Holding Tank present: (yes or no)i,12,!�L
Non-sanitary waste discharged to the Title 5 system: (yes or no)42,!�
Water meter readings, if available:Z/A
A14
Last date of occupancy:
OTHER: (Describe) 'dA
Last date of occupancy-Z22L
GENERAL INFORMATION
PUMPING R CORDS a d $o rce information:
System pumped as part of inspection: (yes or no)
If yes, volume pumped: �J9 gallons
Reason for pumping:
TYPE OF STEM
Septic tank/distribution box/soil absorption system
�Q Single cesspool
,Ul) Overflow cesspool
A Privy
42
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
f
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 562 Poponessett Road Cotuit,Mass .
Owner: David Carlson
Date of Inspection: 6/1 9/97
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron Z4OC _ other (explain)
Distance fro �rivate water supply well or suction line 1114—
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
NO signs of leakage at the joints : Venting of the septic system is
through the house vent.
SEPTIC TANK:L4d'L'' 5?A' aX)S
(locate on site plan)
Depth below grade:
Material of construction: , concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age ND Is age confirmed by Certificate of Compliance 71(Yes/No)
Dimensions: n"ram 11r114`
Sludge depth:Z y-
Distance from to op f sludge to bottom of outlet tee or baffle: -
Scum thickness: 2
Distance from top of scum to top of outlet tee or baffle:TLIA)e—
Distance from bottom of scum to bottQrn of outlet tee baffle:�IkE
How dimensions were determined:
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.) Pump septic tank every 2-3 years : Tnl et & oil tl Pt tP.P4
are in place : Liauid level at cutlet invert i G 5111 - The �qprDtjf-_tank is
structurally so n : The septic shows no signs of lPakane
GREASE TRAP:"QQJe
(locate. on site plan)
Depth below grade:��
Material of construction4iconcretefAmetalm� i bergl as A10 Pol yet h yl en e ej4other(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 baffler
Date of last pumping: kiq
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.)
Grease trap is not presen
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 562 Poponessett Road Cotuit ,Mass .
Owner: David Carlson
Date of Inspection:]/19/97
TIGHT OR HOLDING TANK:1 1�Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grader
Material of construct ion:d&con cretet),l meta M F i berg I assA2Po I yet h y I en e/JAothe r(expla in)
Dimensions: AM
Capacity: gallons
Design flow —gallons/day
Alarm level: Alarm in working order _ Yes; No
Date of previous pumping: AM
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Ti ght, or Hol chi ng tank. arp rnt, nreqpnt
DISTRIBUTION BOX:_Y
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Distribution box is evebox has on y one iaterai to the ieachpl .
No evidence of solids carry over :No evidence of leakage in or out
of the box.
PUMP CHAMBER:A�f/e
(locate on site plan)
Pumps in working order: (Yes or No) �A
Alarms in working order (Yes or No)_�
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
pump—ghg;pbe;p is not present
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 562 Poponessett ROAd Cotuit,Mass .
Owner: David Carlson
Date of Inspection: 6/1 9/97
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type_ n�
leaching pits, number: 1 Hl
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,fength:
leaching fields, number, dime ions: 10
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Cotu' ding:A11 yPgPtgt,; nn
is norma .
CESSPOOLS: "4f-
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: 2114
Dimensions of cesspool: 14114
Materials of construction: 164
Indication of groundwater:
inflow (cesspool must be pumped as art of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
awe gotppesent
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.)
rivy is not present
(revised 04/25/97) Page 8 of 10
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 562 Poponessett Road Cotuit,Mass
Owner: David Carlson
Date of Inspection:6/ 9/9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
t
I �
'00,
f
o �
vob Ale>S57e7T Ate.
i
(revised 04/25/97) Pag• 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 562 Poponessett Road Cotuit,Mass .
Owner: David Carlson
Date of Inspection: 6/1 9/97
Depth to Groundwater&rFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
observation of Site (Abutting property, observation hole, basement sump etc.)
V Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
heck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
We J.P.Macomber & Son Inc have installed several system on poponessett
Road in Cotuit. No water was ever encountered at 121 or more .
Installed.
211 Poponessett Road Permit #84-593
259 Poponessett Road Permit #88-490
338 Poponessett Road Permit# 75-420
(revised 04/25/97) Page 10 of 10
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-TYPE OR PAINT CLEAALY-
PROPERTY INSPECTED
STREET ADDRESS 562 Popponessett Road Cotuit ,Mass .
ASSESSORS MAP , BLOCK AND PARCEL
OWNER' s NAME Richard C�rlson
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.Macomber Jr.
f
COMPANY NAME J PeM4Q9111 & Sow nc1�
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State ZIP
COMPANY TELEPHONE FAX 3 508 1790 1578
R
CERTIFICATION ST�TEMCNT
I certify that I have p"b�sonally inspected the sewage dieposa`1 system At
thi'g address and dial the Jnformation reported is true , accurate , and
complete as of the tjlne of ; nspection , • The inyspection_.. was . performed and any
recoanmendAtlori§ iegrirdin� `u' grade , maitite.rlt�n`ce, and xepair are consistent
with my trr> lnitl atld experience "in the proper!' and maintennn of on
site sewage disposal systems,
Check one :
{XXXXX XXSysteui PASSED
The inspection which I have conducted has not found any information
. which indicates that the system fails to 'adequatel,v protect public
health or the environment as defined in 310 CMR 15 - 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have conducted has found that the system fails to
Protect the j)ublic health and the environment in accordance with Title
5 , 3.10 CMR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
r ,
Inspector Signature Date 6/1'9/97
One copy of this tification must be provided to the OWNER, the BUYER
( Where applicable ) and the BOARD OF HEALT1t,
* If the inspection FAILED , the owner or"'operator shall upgrade ' the ayatem
wit►iin one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd . doc
_ sbyy �/71
THE COMMONWEALTH OF MA.SSACHUSETTS
� DEPARTMENT OF E ONMENTAL PRO CTION
r .
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Dircctor of the - ion of Watcr Pollution Control
TOWN OF BARNSTABLE .
LOCATION
VILLAGE o �y / � r ASSESSOR'S MAP 6Y LOT
INSTALLER'S NAME & PHONE N0.-12_&,_ -S l -3
SEPTIC TANK CAPACITY
p
I'I LEACHING FACILITY:(type) /� �i�ST �� (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER/i .��,�
BUILDER OR OWNER D119 C,-�
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED:
:VARIANCE GRANTED: Yes No
`9
�3
J
f I�
- 7
Fizz
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...-- ....OF . ......12-�
.. . .. ...
------ ---------•-----.-......--:-:. ....
..
Appliration for Elitivniial Works nonotrurfn rrutit
Application is herebymade for a Permit to Construct or Repair ) an Individual
Sewage Disposal
System at
6•........ .. 5'S�TT�_ �O�U �.r...................r
( n o catio -Add ss / Lot No.
W �fawner ..................................
ddress
a . (T`-...........p.............••---••---............................. ......................-...........................................................................
Installer Address
UType of Building / Size Lot............................Sq. feet
Dwelling_ No. of Bedrooms............./_.............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e
a Other—Type of Buildiu g ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures .----•-.----...----•-----------•-------••--•-•--•-••---•-•---------•-•---•--
W Design Flow...........................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity',.� vgalIons Length........
................ Width................ Diameter.......-........ Depth................
Disposal Trench—No. -----._ ----- Width .................. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.___.------j.- .. Diameter.....6...--..... Depth below inlet............. Total leaching area..................sq. ft.
Z Other Distribution box ( 4�-r Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..--.....---............
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 P •-------------------------------•----------•----••--•---....-------••-----.......-------•--••---------•-•---•-•-•-•----........- -------------
Description of Soil.....................-.....................................................................................................................
x
U ---•-------------------••-----•-------•-----•--...-------------•---•--------------•------...------•---••-------•-•-•�-•-•---•--------------•--------- .................................................
W
x ••-•-•-••--------------------------•--•-------•--••-•--••-----------••-••--------------...••--•-.. .-• ----•--•••----------••----•---
o----C.'..... ............ ...
U Natur of Repairs or—Alterations—Answer when applicable_ �''�.� -�---��•.-•.�.--._�-•--•--•--Y-S-21'�
J / T
.....................0----•- -�- ----T /' ----•--�--------1.....-6--�-p..4F_ ?. ------L---....'----•---•-------------...................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of I ITL 11 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate.of Compliance has bee issued b the bo d of h th.
Signe r�Z-''� --- -••--- - `
Date
Application Approved BY .................�� -•-- . 2 '
Date
Application Disapproved for the following reasons-------------------------------------•----------------------•-------------------•--------.......----........--•-
•----------------------•--•--------•------••----------•••••-----------•••-•-•----------•--•-•---- -•--••--- -•-•---••---.
/�, f Date
Permit No... .•--- 2 Issued.............. -- `�`` ..
Date
No. Fes$.._....."`' .': `
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
V............ !`.............OF..............-............. :.
Appliratinn for Disposal Works Tonstrnrtivrn Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System
^'at: n ee-.
�. cation.Add ss..^... .............. «:.. .............----•-•••-•••-••-•••-•---•••-or Lot No.---•--••-
W :? C.. :............
wnen ... Address
a ...................... ...... ........
Installer Address
UType of Building f Size Lot____________________ _____Sq. feet
�-, Dwelling.—No. of Bedrooms.,.........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures .............................................................................
Design Flow..........................................:.gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid*capacity'. ?gallons Length ............... Width................ Diameter---------------- Depth................
x Disposal Trench—No,.......... .... Width__.. ....... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..... Depth below inlet5�....__________ Total leaching area..................sq. ft.
Z Other Distribution box ( �- Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit--------------------
Depth to ground water.....................0-4
.
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ........................................................................--••--•--•-•------•--•••--............................ ------••-------------------
0 Description of Soil...........................................................................................................................................--.............................
x
V ----•-•••-•---•••-----•-----------------------•-•-----•---••••.....•-•----.._..._.._........-----•---••---•-------------••---------•-•--•-•-••--•----•--•---...........................................
W I
x --••-•-••------------- ••-----•••--• ••---•-•-•-•-••---• -•••-•---------••...-----•--------------------•------------------•-•----•-• ........ -------..--------
V Nat r�e�of� �pairs,er Alter do --Answer when applicable..' s_ 'r'�.. .__.�s._ __; ________________r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI T LE 5,of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate-of Compliance has be,n issued_by thhe'j;toard4ofil.ilth,<'., r-
Date
Application Approved B:y_____r _.__. __ _�__.�r_ ____ 2-Y,
Date
Application Disapproved for the following reasons----------------------------------------------------•---------------------------------------------------...•--•--
-------•-•••------•..................•-•-......-•••---•-•--•----........--------------•••-...-•---•-•--.....••--•-----•---------- ----••----............................................................
Date
Permit No._... .G�._.____ / ? /J '
• 6�---...--•----•... Issued.-----•- ', 1 l .............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD (;f HEALTH
..........................................0F......f• ;ice /C/
Trrtifiratr of f omplianr
THIS IS TO CERTIFY, That the,I divi ual ewage Disposal System constructed ( ) or Repaired
b -� .....--•-T .................••--••-----------=----•--_....-
-•..........:.....J•-----•----..........-----•j. Installer '� 1f
at----------•---- 5 � ` ............
c ? 'ri �✓ SS t• 7 J� Cd ?ci
has been installed in accordance with the provisions of TIT a- 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......... .... ------ 2�4 ^______ dated__..._____..r`�_ ._. _ _ ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
••-
DATE...... ...�. ::�4 IF ....... Inspector............. t ----•---- ----------------------••-••---•---•-__----
THE COMMONWEALTH OF MASSACHUSETTS
_ - BOARD OF HEALTH
1 �. .yam
OF....... ......_.
FEE........
Disposal Works �nstrudion rrmit
Permission is hereby granted..........'.. ...............
to Construct ( _) 0y. Repaid ( an Individual Sewage Dis,pos,.il,_Systeig -�
atNo...............-5-•--•-----: ..............................�1_ c,/�� -�. a
Works
Street
Lt- �
as shown on the application for Disposal orks Construction Permit NorJ_;__°:_.___ _ Dated........ 1-'-; ---------------
DATE -------_j i ` Board of Health
_ s'' 1 c f^_'�.----•-
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
P®poness t Bay F.G.37..0 F G.34.0
nnfr�I
34.0 30.5
-;� _ 1500 Gallon Top E1.31.5
--— — -- 33.8 Septic Tank 33.6
_4 __--_____-____— '-,'s— <rr>= Bot.El.28:5
__ =_ ___ ` _ = i_=__� SS-�_ z { c�... c,•:_ 32.0
4.7
Bedding as
ZZ
Z. `_ __ _ _ L'___ _ =zo=_ �, Per Title 5 Bottom of Test Hole El.23.t3
_ — No Ground Water
DELVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM
=_—_ --- _ ______ �� E, Not to Scale
— _ -�
,; ` �•_.�>.• _ _ -~_ s DESIGN DATA NOTES
_ ' � ---------_______ Single Family-4 Bedroom LWaterSupplyForThisLotisMunicipal water.'
m _ _____
`1- ►uksT.wo; >...,..e - With no Garbage Grinder
• ---- Daily Flow=110x4=440 GPD 2 Location of Utilities Shown on This Plan Are Approx.
o At Least 72 Hours Prior to An Excavation ForThis
SepticTonk=440 GPD x 200/0=880 GPD y
Use 1500 Gallon Septic Tank Project The ContractorSholl Make The Required
Notification to Dig Safe(1-800-322-4844)
Not � wo"�4MRu S'
LEACHING AREA
"•� �, / s� � -�\ ��� � ��-� 1 3 The Contractor is Required to Secure Appropriatet
I
\ � •/ , o. � �. z 440 GPD/0.74—
�595'SF Required Permits From Town Agencies For Construction
\ - + d i I
- 2-188 S.F. Define Th s Plan.
.VY, l2 .35
_ Sidewail 2( ) by ,
— — 11
�. Bottom Area-12'x35' 420 S F
4. InstollRisersasRe iredtoWithln 12.of -
i - _\�,6 0 ., � � 608 S.F.SF.Total Provide
'1 \ \\ \ ry v ; ♦e.e ,'y Jj jIfA \� LEACHING CHAMBER DESIGN Finished Grade.
PF',°.°F1001 E'° �f 5.All Structures BuIried Four Feet or More or Subject
�\ o �\ �. All Pipes to be Schedule 40. Use to Vehicular Traffic to be H-20 Loading.
I oo, a �� 4-500 Gal.Leaching Chambers ina
12'x35' Washed Stone Field as Shown 6 Septic System tobe Installed in Accordance With ,
R t \ 9,d /%�' 310 CMR 15.00 Latest Revision And The Townof
-�♦l ® \�� +ti �y5 ' , Barnstable Board of Health Regulations
♦�\♦ I ®F ��'� \`.• ��"'"6tq 1 '� : T All Piping to beSch 40 PVC.
,2f
.FAO A FlFobrk d Flll }�OF �+
^ti �
a {�
rq rL 1
\ -.�♦ �� \ SULLIVAN
., No.29733 -;
\ /• Leaching
3R•—I •: CIVIL ¢
a ` Chamber SDWNQ wudre •. O. 4
I
PLAN VIEW CROSS SECTION OF CHAMBER
...:NOT TO SCALE
Scale: l"=40'
,
T.H. ELEV•3'i•O
a OR&APi1G MArMnaaL SITE PLAN
3 ' --- PROPOSED SEPTIC SYSTEM
BROWN coAr-%s � UPGRADE
E S/".Nt) I OYR V/'S
w%o v %Np 1 AT
B1 Csa S 7;5- R s 562 POPONESSET ROAD
D2 139N'ISH. YEt_. COARSE BAND
„ W/fOBBLES l YR (p/(o
COTUIT, MASS.
C LT, \/EL'1514 ZRN COARSt FOR
i 22„ santQ I ovR `/y DON LAW
TEST HOLE r3v S.E,= I SCALE: AS SHOWN DATE' FEB. 25, 2000
F e Ci. 214 1 2.0 0 0
K10 GRDuNU wA-rER SULLIVAN ENGINEERING INC.
OSTERVILLE, MASS.
.:F .....
i Ki
M II
,I N s a .•� u o
o
yy yr.
, '
a
'I'o / •. .0 0 �� f a •v .
•.A
� ao
40
LOCUS PLAN
Scale:1' =2000'
Assessors Map 7
Parcel 4-1
Zoning RF
Setbacks
Front 30'
Side 15'
Rear 15'
eY .
i
/�� o D +�+
C �
POP000 al �% / p(OP(OM
rdal)
/ y 1
(Td C .� i 000,
�
i/�/i/1�j�i i �„�,,,, c► /i i i �/ /
/ /. /
/i / / / /-' / / / � / / / 13
of
/�/%%j tam e/ / �► „'. /// .00
//,/ /
- - -
00
_ - ----
'0' woo
000,
.01
.5 // %'r.rrr'� ///, r✓//// / // ��►. 9Q 100,y� +..grr". ��a. r � �. +.. �./'�/I /1_.r'. r /////// / /
51
Zone A11 --_=-- 1O_-��-� -. f! .t'►L�,, '!.�%�//��/ �- �0 '� �, r3`s Zone All -- -=- 10-"`��-' ,.. -=�- //'' tom r %ice/ // // // �' V"
-FEMA = �„���.�=` =r==� I . Y /i �/ / // / / —..FEMA��==�• +��,`��"�ram+' ==�, �.+/ // .�' ..' / ,� / // / y
Zone C - - _ _� __. --J �'� .01
%/ /// / / / / �/ Zone C .___ _ ... W`�.•.�,_,, �� �� /i/ �,/_ ./ // // // '
/a�4// / �3 �a.�:"wZ - -- -. - '_-... - _..- ..... --+ � lire E
- -- -- -� - - ----- / / o001,
o .� f _..�• - .... _. _ _ � _� - - - - - -- ��/ •`� "� to / / / 25 / - Of
. 7'� /t5pr\ Rr,P�,/ / 25 // .� .���,. 41 '- ._ r'/ / P�'90/ // / // -., ���► E�\� A3Ac
- - 20 // P/ ���/ / / / // �`i _ - �. - Za '��j�!'r R// .�/ / / .�'' Q'�` RIGNARD
h - -- - 0 -- --- -- --- - ---- =t't1'!� �'' 0�6i/ '� // ' / r N +- - - - - - • •-.' .ij8/,.• ' � _� // // / �// / � � R• ""
_=- -- ------- - -f� / �I / / // '�r / _ _.. ._. _. m - 00
y`_ -_.-... _. - -.. �. - ._ .-. ..y/�010 - "" /• / ' .01 .� '' i N� LF4EUREUX N
.01
1000
Top Of `tea.T` �""��'.� ' \ �•.. ar•��'-''"•��+ — / Top 0f `` aw+'"' +'• - �, r .'- //
�•ate-• ,�. — ...- ..r
Coastal conk / -•� \ ; I T- - ..- _. c►
.-• r - i (by slope deffnitlorr) 1
(by slopedef7nitlon) - - - - - t- - ..... _ - -' _ _ - - - - � - - -' ""- - „ , ,• . - - �;
1 ,
��
- p,fz A� 5
ILILi 'r/ 3 2X1peMpuS a.6C y.REMO p �✓ —
v6D
it
EXISTING / , /
►� e- i At3PNVON y l t0, N / /
F:n /0 gCPTIG S`15TEM ��
\q/pRK'LIM17 LINE 9y
butter
k— O / WITH HAI G3A1.ES• as �"5
ry
t cr
tu SEE NOTE ILU
too '
f \
Lot lA
t 1 A \ ells 56 /�/ f 4000
• --Fes^"'-'_' 3 00 F a l
33,700*SF
-
` mN0011 ` / -1 10well ng /
s duo 4 J Sdo
6 N. 1 S�Rv PIP
M N. T ` o.used 01 oat E\ev. t�*�y� s9 \ I ~' 1 Sty /
N 9.9s IN a 1` PRIMAL r,, �! �/ �t,tQshF _ y \`� ¢ �// �` /� N 6'96• \\ \ Garage
y�v PAP, r ,
Op 4 Q \ .�• 4 + �9 °Q
N.\ \ \\1?�6 o .- 3� ��.c�:��� M OTC. 5 \ •\ ?� w \ \ 0�
sEv•c1c 3 por
W IV ell
�''
•G
i Ile
t'•�ACLrING
, o
S `� \
. /�' � BR8
6401 IR�r
' or4ro ` / tF
NOTE 1: pI5TUR6�:D AREAS W i'rH�N So' ' t° . PU , O� ��� W/Q�e \ o \ fvl�li g
ptlFFEf, TO FJM R GPI.ANTED `" itr789
\ CfVii.
WITH 1-/�w�).
TJ9M Ei-36 5'MSL � 7BM E1-38.5�ISL - w
T of BRB � �`��
T of BRB
�j
I �
ATTACHMENT A
I Note MST NG PLAN VIEW Directions to 562 Popponessett Road, Cotuit:
i The Intent of this plan Is to secure scale I =20 Take Route 28 toward Cotuit; Turn left at the lights onto Putnam Ave.; Take a left onto
!, �vissnr�rlatrrr�.s�err PROPOSED PLAN VIEW Conservation Commission approval Main Street; Take a right onto School Street Take a left onto Crocker Neck 9 Road;
! -" only. It is not to be used for construction. Take a right onto Santuit Road and follow to intersection of Popponessett Road-House
m S474, Scale I = 20 . The drawing Is only valid with an
original stamp and signature.
ANUCAI rsN AM Do N L 19 uJ is on the right #562
'P&PON6sskT- 12p
• No ion:
_. ._.. ._._..... _ tea ev(a
I 17t/e: PREPARED RY PREPARED FOR �
t!ROAJsCT1'1ACAnGN: Cow, AIAsS
PROPOSED SITE PLAN �ulli�ran lEngin�r�ng, ��ic� C � t� I DON LAW ,)The topographic information shown
hereon was obtained by cornentional
" 3 ° '°order°rca»&ti°n' p `° 562 POPONESSET ROAD survey methods.
co PO Box 659 PO fax 718 C/0 BRYER ARCHITECTS
�- Ostervllle, MA 02655 Hyannis MA 02601-&0718 160 SECOND STREET 2)The property information shown hereon
cat awk0m _ COTUIT, MASS -CAMBRIDGE MASS
(508)428-3344 (508)428-3115 fox (50e)790-7902 (5W) M5 &x ' was complied from available record
PSulIPEObol.corn copealu► capecti�net information and does not represent an
Order of CM&d=Ad 6110100 CON. COMM. C011A Iv1 E N TS O p
2/25/Od_. .NSW 110uSE FOOT PRINT 20 O 10 actual on the ground survey.
�a ao eo Field: RRL RJM Oroft:
Mills Plu w2l by co on •7 2/ 49 NOW 14O U S K Fool P R I N-r — 3)The datum used is approximate mean !
aq d/G/9�r ADDED LOw SHRUB t3ur=>=ER Date: SCaI@: a Cor'n'p•: Review: sea level. See plan for bench mark set
REVISION 1/8199 ADDED PRC)PoSEO house November 4, 1998 1 =20 Pro; Drowing