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HomeMy WebLinkAbout0624 POPONESSETT ROAD - Health Jr 624 POPONESSETT ROAD, C^,'OTUIT A= 007 601 ) l � I, (iA 'fl 1 ) f Sep 30 2019 23:15 HP Fax page 46 00 -Dot . Commonwealth of Massachusetts p Title 5 Official Inspection Form 'R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r fi 624 Poponessett Roada Property Address Paul Embree Owner Owner's Name information is required for every Cotuit ✓ MA 02635 9-27-19 City/Town/Town State Zip Code Date of Inspection page. tY p 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. ```��.11au l aF a 1rri,(11& Important: on forms when fillingng out A. Inspector Information �� '�'�I � ?:' '• y on the computer, `��:' JA M E S ••N use only the tab James D.Sears = ; ;m=_ key to move your Name of Inspector cursor-do not Capewide Enterprises �,�'• o o:• kee the return Company Name .... G� y p y `R� 153 Commercial Street a►Ii1r�`�� 1�11 Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.34D of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true,accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9-28-19 pector'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. 15insp.doo•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page t of 18 r Sep 30 2019 23:15 HP Fax page 47 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 V � 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is required for every Cotuit MA 02635 9-27-19 ' per, CitylTo%vn 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: The system is a 1000 Gal. Tank D Box and pit. 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 serptic 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): 15insp.doc•rov.7)2612016 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 Sep 30 2019 23:16 HP Fax page 48 Commonwealth of Massachusetts Z Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Poponessett Road Property Address Paul Embree Owner Owners Name Information is required for every Cotuit MA 02635 9-27-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) 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 pipe(s)or due to a broken settled or uneven distribution box. System will to broken or obstructed , 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 InspecW Pam:Sibsurface Sewage Disposal system-Page 3 of 18 Sep 30 2019 23:16 HP Fax page 49 Commonwealth of Massachusetts Title 5 Official Inspection Form rt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Poponessett Road Property.Address Paul Embree Owner Owners Name information is required for every Cotuit MA 02635 9-27-19 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 ❑ & Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.M&2018 Title 5 OfWel Inspection Form:SuberMece Sewage Disposal System-Page 4 of 18 I Sep 30 2019 23:16 HP Fax page 50 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form kv',v Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is required for every Cotult MA 02635 9-27-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level In the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in risalMillill is less than 6"below invert or available volume is less than %day flow P17 - ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped; ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4. 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 t5lnsp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurtece Sewage Disposal System•page 5 of 18 Sep 30 2019 23:16 HP Fax page 51 c Commonwealth of Massachusetts ,k t� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vw)� 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is required for every Cotuit MA 02635 9-27-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat,or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or "no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facilfty or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan,at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.M612018 TWO 5 Official tnspecilm Form:Subsurface Sewage Disposai System•Page 6 of 18 i Sep 30 2019 23:17 HP Fax page 52 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1� 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is required for every Cotuit MA 02635 9-27-19 per. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal.Tank D Box and pit. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No information in this report.,) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2017-116,000GaI201E-73,000 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occu anc : Present P Y Date t5insp.doe-rev.7/2 612 0 1 8 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System Pape 7 of 10 I Sep 30 2019 23:17 HP Fax page .53 ' f Commonwealth of Massachusetts Title 5 official. Inspection Form I° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Poponessett Road " PropertyAddress Paul Embree Owner Owners Name information is required for every Cotuit MA 02635 9-27-19 page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commerclalllndustrial Flow Conditions: Type of Establishment: Design flow(based an 31 C CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes,discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.1126/2018 Title 5 Oftial Inspection form'.Subsurface Sewage Disposal System•Page 6 of 18 Sep 30 2019 23:17 HP Fax page 54 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is required for every Cotuit MA 02635 9-27-19 page. City/Town State Ztp Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA 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: 1994 Permit#94-26912017 permit#2017- 115 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 28"teat Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feel Comments(on condition of joints, venting, evidence of leakage, etc.); Pipeing is 4" PVC SCH -40. tsinsp.doc•rev.7/26/2018 Title 5 Of vial Inspection Forn:Subsurface Sewage Disposal System•Page 9 of 18 Sep 30 2019 23:17 HP Fax page 55 Commonwealth of Massachusetts ' Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is Cotuit MA 02635 9-27-19 required for every page. City/Towm State Zip Coce Date of Inspectlon D. System Information (cont,) 6. Septic Tank(locate on site plan): Depth below grade: 16" P g feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29' Orr Scum thickness 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 determined? Asbuilt-Plan-Tape Sludge Judge 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. Tank and covers at 16" below grade. In and outlet Tee's. No sign of leakage or over loading. t5insp.doc rev.712 812 0 1 8 Title 5 Official Inspection Form:Subsurface savage Disposat System-Page 10 of 18 Sep 30 2019 23:18 HP Fax page 56 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments vwv- 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is required for every Cotuit MA 02635 9-27-19 page. CItyfTown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 15insp.doc-rev.712612018 Title 5 Official Inspection Form.Subsurface Sewage Disposed System-Page 11 or 18 Sep 30 2019 23:18 HP Fax page 57 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is required for every Cotuit MA 02635 9-27-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 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): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-2' below grade wlcover at 8". Box is clean and solid w/one line out. No sign of over loading or solid carry over l t5insp.tloc•rev.712 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal system Page 12 of 18 Sep 30 2019 23:18 HP Fax page 58 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .u 624 Poponessett Road i Property Address Paul Embree Owner Owners Name information is Cotuit MA 02635 9-27-19 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.): '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: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length, ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Type/name of technology: Onsp.doc-rev.712612018 TU 5 official inspection Form:5u0surfece Sewa5e Disposal System-Page 13 of 18 Sep 30 2019 23:18 HP Fax page 59 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form • Not for Voluntary Assessments > 624 Poponessett Road Property Address Paul Embree Owner owner's Name information is COtUIt MA 02635 9-27.19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) r 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Precast Pit w/2' stone. Pit and cover at 22" below grade. Pit wet bottom w/clean wall's No sign of over loading or solid carry over. No high stain line. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7f2a/20 18 I Title 8 01flclal Inspecdon Form;Subsurface Sewage Disposal System•Page 14 of 18 G Sep 30 2019 23:18 HP Fax page 60 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Po onessett Road Property Address Paul Embree Owner Owner's Name information is required for every Cotuit MA 02635 9-27-19 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): , 15insp.doc•rev.712612018 Tile 5 Official Inspection Form Subsurface Sewage Disposal System•Pape 15 of 18 Sep 30 2019 23:18 HP Fax page 61 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is required for every Cotuit MA 02635 9-27-19 page. dty/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 t5insp.doc•rev.7/260018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page".6 of 18 n Sep 30 2019 23:18 HP Fax page 62 C oTv rT P o r 3 o Sep 30 2019 23:18 MP Fax page 63 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is Cotuit MA 02635 9-27-19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check.Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 24' Estimated depth to high ground water: 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 propertylobservation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Towne G.W. Maps ❑ Checked with local excavators, installers -(attach documentation) . ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G W at 24' per town G W Maps Bottom of pit at 8' below grade. Bottom of pit at 16'above G.W.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 ti Sep 30 2019 23:19 HP Fax page 64 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Poponessett Road Property Address Paul Embree Owner Owner's Name information is Cotuit MA 02635 9-27-19 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: . ® 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 V_ v o t5insp.doc-rev.Tr282018 Title 5 Offoiel Inspection Form:Subsurface Sewage Disposal System•Page 18 o1 18 z r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , M 624 Poponessett Road is Property Address ► Bob Colgan Owner Owner's Name r• . information is M. it MA 02635 5 t Cou -3-17 required for every a page. City/Town State Zip Code Date of Inspectionls�y NJ 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 A. General Information /o7o29u7 on out forms #the computer, I `�p �g"OF Aqoq' v1,,, use only the tab 1. Inspector: �� •• �s' key to move your cursor-do not ,lames D.Sears JAMES m use the return Name of Inspector = ;ti key. * , Capewide Enterprises A r� Company Name '�i�,FcfV T I�-I •G���� 153 Commercial Street 'o,,,���sf iN SP`E`\�p•` Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 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 5-3-17 pector'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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M s 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and pit. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 page. CitylTown 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): ❑ 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 t5ins.doc-rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in is less than 6" below invert or available volume is less than %day flow kp/T- t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 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 the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 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 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2015-89,000GaIs2016-88,000GaI's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: . Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease,trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is Cotuit MA 02635 5-3-17 required for every , 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.cloc-rev.6/16 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 °M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is Cotuit MA 02635 5-3-17 . required for every 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: 1994 - Permit#94-269/5 -2017 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28" 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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): 16" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is Cotuit MA 02635 5-3-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge 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. Tank and covers at 16" below grade. In and outlet tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is Cotuit MA 02635 5-3-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No. Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 2' below grade w/one line out. Box is new 5-2017 w/cover at 8". 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.doc-rev.6/16 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 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ 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 a 1000 Gal. precast pit w/2' stone. Pit and cover at 22" below grade. 6"water in pit w/clean dry wall's no sign of over loading or solid carry over. No high stain line. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is Cotuit MA 02635 5-3-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids - Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 7 Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i naI p CPO" F33E/T /('A c o T P a o � g ,4RA �£ 0 o � 'DRi �£ Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is required for every Cotuit MA 02635 5-3-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to JW ground water: 24 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: Town G.W. Maps. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: G.W. at 24' per town G.W. Maps. Bottom of pit at 8' below grade. Bottom of pit at 16' above G.W. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 624 Poponessett Road Property Address Bob Colgan Owner Owner's Name information is Cotuit MA 02635 5-3-17 required for every 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _y Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Miqogal *pgtem Con.5tructiou Vermtt Application for a Permit to Construct( ) Repair(K Upgrade( ) Abandon( ) ❑ Complete System X Individual Components Location Address or Lot No. 6;t y POPDjV!�5 7- Owner's Name,Address,and Tel.No. C C-01-4/4A) I r Assessor's Map/Parcel 00 7 (Pot y( Gxda6 � 1�'t(f05S-rP&T 1 LG q,�i 4"LA Installer's Name,Address,and Tel.No. 502-qz7-8%'77 Designer's Name Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building R654949kJ7l,41_ 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) __TAJ5 T0rU— [V cri 19-Rj o)� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date �'� 1-7 Application Approved by Date YQ1s 0 Application Disapproved by: Date for the following reasons Permit No. Date Issued c ' No. Fee ` l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mi5po!6a16p5tem &n truction permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. 6;I LI pop0tVE 5$�?T RD Owner's Name,Address,and Tel.No. ! COTUc?' aOteFLT GO4-41 Al Assessor's Map/Parcel 007 OO t o?q l GAW6 J?' C45s'rNgr ti I44/ Af ` Installer's Name,Address,and Tel.No. sC)g-q 77-n 77 Designer's Name Address and Tel.No. C,4,�,()c c;ajst-s .Sz Type of Building: f , Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) s Other Type of Building R« etcgtA No.of Persons Showers( ) Cafeteria( ) Other Fixtures n Design Flow(min.required) gpd Design flow provided gpd �y a Plan Date Number.of sheets Revision Date Title J Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -'dJS"jAt_1 - AJECeJ D"12J��' 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 Environ'mental Code and not to place the system in operation until a Certificate of Compliance has been issued by-this Board of Health. � � it Signed —y� \`Fz , ( Date Application Approved by fr y� �' ,�� Date Application Disapproved by: Date for the following reason's Permit No. r�() �1 Date Issued L t 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 CA P CW!b G r✓07C— Q kI S-GS at 6 a 76 PzweS5 C7-r P_oAD QQT Q L( has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer dAP9U)fDC1 Designer N�i4 #bedrooms Approved design flow gpd The i suance of this permit shall not be construed as a guarantee that the system will fuRrittionn,as designed. Date.. ' / �j< •' �j Inspector No. Qo 0 .. 1 `� Fee f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1=i5po.5a1 *pgtem Con5truction Permit Permission is hereby granted to Construct ( ) Repair ( X) Upgrade ( ) Abandon ( ) Systemlocatedat 62a4 POP&Q-ESSE?T I64b C0-rU( -r 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 permit. Date 1.1 1 [C7 Approvedby �1r11�1� � ( c f-, r Commonwealth of Massachusetts Executive Office of Environmental Affairs ~J� Department of Environmental Protection i '� William F. weld UL 5 1 ,�� : Governor � Trudy Coxe Secretary,EOEADol David B. Struhs . •Commissione r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 9 CERTIFICATION Property Address "vac �� ��A'r'��e�`3�� _ (c� Address of Owner: 0 j�e" Date of Inspection: "T (If different) Name of Inspector �,i�1 e—r\�y�, Company Name, Address and Telephone Number. CERTIFICATION STATEMENT 1 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 Evaluation By the Local Approving Authority _ Fails Inspector's Signature:" Date: 7 The System Inspector shall submit 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 appropria!e regional office of the Department of Envi,:onmental Protection. The original should be seer, t(., !r,e systen) owner and copies sent to the buyer, if applicable and the appro%ing au;t-;orit). INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: _Z1 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. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined.(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or eAltration, 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 8/15/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617)SWI049 • Telephone(617)292-5500 ��, Printed on Recycled Paper v r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10;--t cs`1� Owner: tC�► rT Date of Inspection: 7�- 1� -�� B] SYSTEM CONDITIONALLY PASSES (continued) 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 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: 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ 1 he wstem ha4 a septic tank anu son absorption system and is witiiiil 100 Iccj to a sollaCc Vvn ii supNl) or tributary to a surface water supply. _ the system ha, a septic tank and soil absorption system and'is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and 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• D] SYSTEM FAILS: 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. _ Backup of sewage into facility or system component due to an 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 i cesspool. (revised 6/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /� CERTIFICATION (continued) Property Address: 4�-`� PC'! Owner: 1E Date of Inspection: D] SYSTEM FAILS (continued): (� 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the 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. Any portion of a cesspool or privy is within a Zone I of a public well. /y 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: h, The following criteria apply to large systems in addition to the criteria above: 1 The design flow of system is 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: 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 suppiy 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, . 7 � I (revised 8/15/95) 3 I a _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART B CHECKLIST Property Address:. �� / �C7/ rim, J '-�( - C C f>•I c� i �— Owner: Gi.IC yt {�-fi-1 Date.of Inspection: 7— Check if the following have been done: i/fumping information was requested of the owner, occupant, and Board of Health. U/N//one 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. 5 built plans have been obtained and examined. Note if they are not available with.N/A. t—Rie/facility or dwelling was inspected for signs of sewage,back-up. -LI-4e system does not receive non-sanitary or industrial waste flow ; _L__�e site was inspected for signs of breakout. ��4 system components, excluding the Soil Absorption System, have been located on the site. S. -'fl e 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 existing information or approximated by non-intrusive methods. fie facl;i;, o•'•;•i'" ".: o;c:i;;d:',;:; if c'"'er^^' f': were pr0vIded +'!th in on the proper maintenance of Sub Surface:Disposal System. (revised 8/15/95; 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: tar.J� Y �'�CI�Ci/irk r;r, j�` C_!.>✓ C, J �w" Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: l� gallons Number of bedrooms: Number of current residents: Garbage grinder (yes or no):�� Laundry connected to system.(yes or no):y Seasonal use (yes or no):-ZY Water meter readings, if available: Last date of occupancy:�^`��`"�c:. COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe)- Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)_ If yes, volume pk,mped: gallons Reason for pumping: TYPE OtiSS'STEM. JL 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)r�r (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �T 12-o <,-�eT.-re, Owner: r Date of Inspection. SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Sludge depth:_ r Distance from top of sludge to bottom of outlet tee or baffle:Jr Scum thickness' Sri Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom,of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffl s, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth belo,.%, grade: . Material of construction: concrete _metal _FRP _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from botto! J" tlnttnrr nt ()tltlpt tee or hattle' 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.) (revised 8/!5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address: �/�t�0 e�-C.�".�r.:j`7 - CCy Owner: Date of Inspec i h. TIGHT OR HOLDING TANK:,/ (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP _other(ex, lain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches,.etc.) DISTRIBUTION BOX: (locate on site plan; Depth of liquid level above outlet invert: Comments: (note ii levei and distnbutiui, r. t•yuo , e�*Idcnce of surd: c-;r)u,,er, evidence of leakage into or out of box, etc.) if oc) PUMP CHAMBER: (locate on site plan) Pumps in working o-rder:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (Z Owner: Date of Inspection: 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: leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition pf vegetation etc.) eo'_�S cJ CESSPOOLS: (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 ground��ate:. inflow (cesspool must be pumped as part of inspection) R Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) B r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: An Owner: ; Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' f'q, J r DEPTH TO GROUNDWATER Fr Depth to groundwater: feet method of determination or approximation: Act 1 t 0 iy , O e--- (revised 8/15/95) t 9 j/ TOWN OF BARNSTABLE ' LOCATION�d ' ����a�es�� �c�. SEWAGE. # VILLAGE ASSESSOR'S MAP & LOT00mll-OCI INSTALLER'S NAME & PHONE NO. ����,. (p,,� ZJ�C2 � SEPTIC TANK CAPACITY _/000, �g ' LEACHING FACILITYAtype) Ire (size) /per � NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BA R OWNER ' x1 t_I6 DATE PERMIT ISSUED: { ' DATE COMPLIANCE ISSUED: r� a VARIANCE GRANTED: Yes No 6� v Ce lA /O,O f�ws�fd+�k TOWN OF BARNSTABLE LOCATIOh ��� /'�� . SEWAGE # 5�-- 0 VILLAGE , J ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ljjdQ LEACHING FACILITY:(type) (size) NO. OF BEDROOMS .3 PRIVATE WELL OR PUBLIC WATER BUILDER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ✓ f�t . Do7 , ©off No....f.. - .� /FEiz /0.0......... APPROVED THE COMMONWEALTH OF MASSACHUSETTS Bil,rnmble C n►etion 0epanment:.B O A R D OF HEALTH ° G n OWN OF BARNSTABLE te Appliration for Uinpooal Works Tonitrnr#inn rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: r ► 4°�. ocatio - -\ dre or Lot No. � '�11 �.`� ---------------- ---.............------------------.........--------- wner Address a ` . ....._. � Bey------------------- Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms_______________ --_--Expansion Attic ( ) Garbage Grinder ( ) ►-� — Other—Type of Building yp g _.�f-�__���/4. No. of persons.......... ________________ Showers (p'� Cafeteria ( ) a Other fixtures ............... ........................... W 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 inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ aa _ 'Tesf Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ RS --------•------------------------------------------------------------------------------=------------......................................................... 0 Description of Soil........................................................................................................................................................................ x V ---------------•------------------------------------------------------------------------------------------------------------------------ ------ W ........---•----------------••--....---......_.....----------------•-------------------...._.......-----------------------------......................................--•---•--•- ._..._.....-.---•-- VNature of Repairs or Alterations—Answer when applicable..-.-.-_� -- ��`----___ m il/...._._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ........ ................... ............ .. ............................... ................................:...... Dace Application Approved By ---------- d.a L ---------------------------------------------------------------------- J,— Da , ^te Application Disapproved for the following reasonr: ................ ........... `.. ........................ ................... .. . ........... . . ..... ........................... ..... ........ .......... .................... . ......... .................... ................. Permit No. ....... --=1... -1�-.c�--------------------- Issued ..... . . ..............------------------------ Date . Dare i r'} oa 7 GO No....... F>�s..:.....�� ?. .>.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �-'" ---� ;k9m-ytiyTOWN OF BARNSTABLE Appliratiutt for Bi-nip 3Ml Works Towitrur#inn rani# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........... y -�?��E ............(-V ----------------------•-.--.-•-------------------.............. o�ati I -A dres or Lot No. (� �� ._. 1 ----.•---- --------------------------------•......-- .............................................. caner i Address Installer Address Type of Building Size Lot............................Sq. feet �. Dwelling— No. of Bedrooms--------------- ------------------------Expansion Attic ( ) Garbage Grinder ( ) 004 Other—Type of Building __a-5 ���rr�No. of persons........... Showers (p2) — Cafeteria ( ) 134 Other fixtures ------------------•-----------------• . w 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 inlet.............._..... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results .Performed by.......................................................................... Date......................................... aTest Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit--------_........... Depth to ground water........................ �+ ----------------------------------------------------------------•----------------------.._......_....... ODescription of Soil...........-••--------------------------------•-------•--••--------•----•-------•--•--------••---------....-•-------•---•---•--•--••--••---•--------•----------....... x U .......................................................----------•--------------•-------------------•-----------------------------------•----------------------•-------------------...•................ w V Nature of Repairs or Alterations—Answer when applicable.____-_. ____�------_ .._.__ !!iJ !1 F a.(/........ Agreement: V The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -------------------------------------------------------------------------------------------------------- ..............................:...... Dace Application Approved By ............�� .. , .�. --�- �°t-...... .. ;3'" �,.. . i Application Disapproved for the following reasons: ... . . ......................... . . ........ .... . ....... . .................... ... ............... . -- .................... . ... ... ................... . . ............................... ... . .... ................................ Date Permit No. .......7H........ Issued ................................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Qxr#ifiett#E of Contyliance THIS IS TO CERTIFY, -11-at the Individu l Sewage Disposal System constructed ( ) or Repaired( ) by -------------------- G... .:i -------- o..... �.../� Q< at ........................C ------------..- --------- ....... ._................ ................ ............. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......?0-.. .�,..C�.......... dated . THE ISSUANCE OF THIS CERTIFICATE SHALL'NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _ DATE. ` � '�. -�!'�'• _.: ...... .. .. .. -------_._ ..,- -------- Inspector ,_._.... _............ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.. � TOWN C�nn��ri�r#inn �.eruti� t � � Permission is hereby granted-------- --..�1 C __....._ � ? ' to Construct ( ) or Repai ( ) an Individual Sewage Dis o�sal Street ystem at No...........n . L� .........., � �� �J - �y '" as shown on the application for Disposal Works Construction Perm it o.,....__-----� __ Dated........................................... ---------------------------------••--------- � Board of Health DATE......... ----•� -•---- . FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS Q I I d 7 45A*_Y, Zomc 2r so'115'15' I Al OA 10 Oq ID 4. �/v Iry � ,s, � y�T 29•Z � �o. / . . .'' 24-4 00, //lo Ael RZOP i f r I `f# V-aoy,' q t \ 4'° peorPi r �i 16 sF 1 tides ,- 2L. T� , 0 n? FF Alt 161I r , jFins z5.3 `� 1,ES14,d DATA, tk✓ ^`, sc 4a 1z AlVO /NY lk,t �. -M- - SIIJ�L F�4IL°� +3efCrt�3�t�T ' �a z z`%V ro i t ( Pxvj = 3 pc.I Ib G 3,30, GAT (� F S�TiG TAt1L'. -' 30 ICI °��' 4g56'� € TA wlz -i U-,e coact rac�a� � �CO vJ " , I EL=r5 5('1JE t1,JAt-1.. ,�1;+��� I8� SF �,.-�.� � °' �!c� �-�j• 1�- �`�EL�- I 1 Au- � L{"ca"R'��? `.� ^ TX-1iTnA✓1 /��Q — `7& SF t ov� III n p t L"1 VIOF f Y- rZA j DERV, % o SULI_IVr,PJ t No. 29733 m r a