HomeMy WebLinkAbout0068 PRUDENCE LANE - Health 68 Prudence Lane
cotuit ,
A= 040 - 051
Commonwealth of Massachusetts d-p
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments q1.0
68 Prudence Lane _
v� Property Address
Christopher Beamish R
Owner Owner's Na e
information is Cot l� MA 02632 October 11, 2018 T�
required for every
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer,
use only the tab Patrick T. Sullivan_
key to move your Name of Inspector
cursor-do not Ready Rooter Excvating
use the return Company Name
key.
PO_Box 89
Company Address
Forestdale MA 02644
�. City/Town State Zip Code
. 508-509-0802 S112843
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
October 12, 2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
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t Commonwealth of Massachusetts
i
-;2 Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is required for every Cotuit MA 02632 October 11, 2018
— _ _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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 deter/mined" (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 infilt�ation or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass Inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that,the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7!26I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is required for every Cotuit MA 02632 October 11 2018
—_
page. CityrTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board .of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ElY ElN ❑ 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 he Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed % ❑ Y ❑ N ❑ ND (Explain below):
i
i
3) Further Evaluation is Required/by the Board of Health:
❑ Conditions exist which require further evaluation by the Board.of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the`system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
i
Z Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Prudence Lane
Property Address
Ch_ristoQher Beamish
Owner Owner's Name
information is required for every Cotuit MA 02632 October 11, 2018
- _
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:
I
❑ 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:
1
"* 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. i
c. Other:
i
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.7/26/2018 Title 5 Official Inspection form:SUbsUrface Sewage Disposal System•Page 4 of 18
AN
Commonwealth of Massachusetts
Ip Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c �( 68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is
required for every _Cotuit MA 02632 October 11, 2018
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 cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
Required El � q ed pumping more than 4 times In the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15:303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within/400 feet of a surface drinking water supply
❑ ❑ the system is wit hin 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is/located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is required for every Cotuit_ MA 02632 October 11 2018
--_
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
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 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))
t5insp.doc•rev.7l26I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is Cotuit MA_ 02632 October 11 2018
required for every � _
page. Cityrrown 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): 340 GPD
Description:
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 ears usage d 2017+2018= 78
9 ( Y 9 (gP )) GPD
Detail:
Property has been used part time year round for past two ears.
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
v _
Property Address
Christopher Beamish _
Owner Owner's Name
information is required for every Cotuit MA 02632 October 11 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): J Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc'.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank presen4? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes El No
Water meter readings, if available:
Last date of occupancy/use-/ Date
Other(describe below):
3. Pumping Records:
Source of information: No previous record found
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
f
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is required for every Cotuit MA 02632 October 11, 2018
- -__
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Septic tank installed aprox 1980. D-box and leach system installed 08/29/2005
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 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.):
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is required for every Cotuit MA 02632 October 11 2018
_ - _---_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 16"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: 8.5' x 4.5'x 5' 1000 gallons
3"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 31
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
3" i
Distance from bottom of scum to bottom of outlet tee or baffle 1 1
How were dimensions determined? Dube and tape measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade.
Recommend maintenance pumping everLWo years.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is Cotuit MA 02632 October 11, 2018
required for every
page. City/Town 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 Elmetal Elfiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of o let tee or baffle
Distance from bottom of scumZmendations,
ttom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping reco 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:
i
❑ concrete ❑ metal /❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: -
Capacity: gallons
Design Flow: ; -
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
► p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is
required for every C_Otult MA 02632 October 11, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: / ❑ Yes ❑ No
i
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and flo 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.):
One inlet, two outlets. Speed levelers in place. D-box is 38" below grade, H-10. No high water
staining_over outlet inverts. No solids carryover. Riser brings cover within 8" of grade.
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is Cotuit MA 02632 October 11 2018
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: j� ❑ Yes ❑ No`
Alarms in working order: % ❑ Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
--- /
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 gal ea. w/
4' stone
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: —
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
;p Title 5 Official Inspection Form
'`I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
u-
Property Address
Christopher Beamish
Owner Owner's Name
information is
required for every Cotuit MA 02632 October 11, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Chamber located and inspected with camera. No standing liquid with damp base at time of
inspection. No staining on side wall. Clean stone visible in sidewall. Chambers are 4-5' below grade.
No vent found._
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration j
Depth —top of liquid to inlet invert -
Depth of solids layer /
Depth of.scum layer
Dimensions of cesspool
Materials of construction
Indication of roun w g d ater inflow/ ❑ Yes ❑ No
Comments (note condition of'soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.706/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�. -p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is required for every Cotuit MA 02632 October 11, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan): /
Materials of construction: /
Dimensions /
Depth of solids —
Comments (note condition of soil, signs of by aulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. � 68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is required for every Cotuit _MA 02632 October 11, 2018
page. Cityrrown 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
I
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0
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
Commonwealth of Massachusetts
o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
68 Prudence Lane
Property Address
Christopher Beamish
Owner Owner's Name
information is required for every Cotuit MA 02632 October 11, 2018
__
page.. CitylTown State. Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam.-
El Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: >5feet
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: 8/18/2005
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database-explain:
maps.mass is.state.ma.us/oliver.php
You must describe how you established the high ground water elevation:
Test hole in 2005 to 147" (elv= 39)found no ground water. Base of SAS at elv= 44.86 per engineered
plans.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�^ ;p Title 5 Official Inspection Form
Tl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane _
Property Address
Christopher Beamish
Owner Owner's Name
information is required for every Cotuit MA 02632 October 11, 2018
_
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
�p SHE Tp�
Town of Barnstable Barnstable
AUhericaCiiy
Regulatory Services Department p
BARNSCABLE,
,�� Public Health Division m
TED MAI A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: .508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 06 0810 0000 3524 5485
November 9 2011
Jillian& Mark Gent
68 Prudence Lane
Cotuit, MA 02635
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
1301 Old Post
The septic system located at 68 Prudence Lane, Cotuit, MA was last inspected on
8/2/11, by Ricky L. Wright, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• At time of inspection tank appeared to be leaking. Water levelvas down to
the seam.
You are ordered to repair or replace the septic system within two (2) years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
omas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\conditionally passed\68 Prudence Lane,Cotuit.doc
Town of Barnstable Barnstable
Epp tHF Tp��
Regulatory Services Department j�'ga�j
-+ BARNKUABLE, + O D
9 MASS. $tG 3 q, Public Health Division
Gpp `0
'Fb A, 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A. McKean,CHO
CERTIFIED MAIL # 7011 0470 0001 4525 5396
October 4, 2011
Mr. & Mrs Mark Gent
2 Jillson Street
East Sandwich, MA 02537-1266 /
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 68 Prudence Lane, Cotuit,MA was last inspected on
8/11/11, by Ricky L. Wright, a certified septic inspector for the Sate of Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• At time of inspection tank appeared to be leaking. Water level was down to
the seam.
You are ordered to repair or replace the septic system within two (2) years from the date
you receive this notification.
Failure to repair/replace the septic system with the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
omas McKean, R.S., CHO.
Chairman
Q:\SEPTIC\Letters Septic Inspection Failures\Town of Bamstable.doc
No.
— � Fee �1U
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftPlitation for MisposaY 6pstrm Construction 3permit
Application for a Permit to Construct( ) Repair(Upgrade Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. L N Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel v d Q LV S %( I-
Installer's Name,Address,and Tel.No. Designer's Name,Address,6d Tel.No.
�cl ti^ eV\ -1 2 C6,1S'�"� A
Type of Building: ---09 - _-Z 7, r. 9 IY3
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) `Ze?"g- US Ivy 6 TArD sL
�Alun� Leak- SnSl�t (00 U &11 Qy)
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 He
Date
Application Approved by IhM 1 ; Date /
Application Disapproved y Date
for the following reasons
Permit No. 3 5-0 Date Issued D/11 I
---------------------------------------------------------------------------------------------------------------------------------------
t. 6
No. P Fee /0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplitation for Disposal *pstem Construction VgTmi
Application for a Permit to Construct( ) Repair(L'-.*,Upgrade( ) Abandon( ) ❑Complete System N 4ndividual Components
Location Address or Lot No. rOm CPO L /✓ Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel L04 v I t 0q0- �
Installer's Name,Address,and Tel.No.. Designer's Name,Address,and Tel.No.
C6ASk NA
Type of Building: -Z 7 9
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number,of sheets Revision Date
Title 4
Size of Septic Tank Type of S.A.S. I
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) e QF i(L TG,n 1 VS o
f4?0� /00 U
A*
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 Heall
R I
ed Date /6 /
A lication A roved b Date u 5
rr rr Y
_Application Disapproved y Date
for the following reasons �.
Permit No. G ( — 3 S0 Date Issued
------------------------------------------------- - ----------------------_---.--- - -------------
1 THE COMMONWEALTH OF MASSACHUSETTS
s S-QCA CC- "`} �� ��'� BARNSTABLE,MASSACHUSETTS `
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Q,/� Upgraded( )
Abandoned )by v y
at -L)-4-e nC.S— f e/ has been constructed in accordance
with the provisions of Title 5 and the to Disposal System Construction Permit No. v I' - U dated
Installer (I
An
Designer Al lyq
#bedrooms Approved design flow gpd
The issuance of this permit shall not be 4onstrued as a guarantee that the system ill f inc ' n as s' ed.
Inspector -�-a
Date '
r
No. 0 3 yo Fee (mac
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal �&pstpm Construction Permit
Permission is hereby granted to Construct
( ) Repair(✓) Upgrade( ) Abandon
System located at ( ) t
t '� Fry c�-v\(^�_ L N, Co r- t
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Constructio musj a completed within three years of the date of this permit.
Date / Approved by
i
i
of"tKaE ram,
Town of Barnstable Barnstable
Regulatory Services Department ;eicaC 1
+ BARN.SCABLE,
9 MASS, Public Health Division i639. �m m
Arf°a�A+a. 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7011 0470 0001 4525 7604
8/24/2011
Jillian& Mark Gent
68 Prudence Lane
Cotuit, MA 02635
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5.
1301 Old Post
The septic system located at 68 Prudence Lane, Cotuit, MA was last inspected on
8/2/11, by Ricky L. Wright, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• At time of inspection tank appeared to be leaking. Water level was down to
the seam.
You are ordered to repair or replace the septic system within two (2) years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
P ORDER OF THE BOARD OF HEALTH
__... ,
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\TEMPLATEI.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
,
page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be'altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, rTL
C �
use only the tab 1. Inspector:
key to move your
cursor-do not Ricky L. Wright
use the return Name of Inspector 7
key.
B & B Excavation, Inc.
ray Company Name
14 Teaberry Lane
Company Address
Sandwich MA 02563
CityfTown State Zip Code
508-477-0653 S14595
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 CMIR 15.000).The system:
C)
❑ Passes ® Conditionally Passes ❑ Fails-, -
f
❑ .Needs Further Evaluation'by the Local Approving Authority ;
s. 8/2/11
Inspector's Signature Date tCM
�.A
The system inspector shall submit a copy of this inspection report to the Approving Authori�y(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system.owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
` the same or different conditions of use.
t5ins•09/08 l Title 5 Official Inspection Form:Subsurfa4Sewagsal lsyr,Ipl-1 of
1
{
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°M0 68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. _
Comments:
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. 3
❑ Y ❑ N ' ❑ ND (Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):,
El 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'M 68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
page. Citylrown 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 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:
At time of inspection the septic tank appears to be leaking around the seam water level was down to
seam.All other system components appear to be in grate working order,leaching was dry at time of
inspection.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•09/08 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
°M 68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit s Ma 02635 8/2/11
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
❑ r ❑ 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
❑ ❑ ahe 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.
!Sins•09/08 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
c�M 68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
page. Cityrrown 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)
2 ❑ Was the facility or dwelling inspected for signs of sewage backup?
® ❑ 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
g ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Dec.2010
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
r 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
II
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: - Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes'or no) (if yes, attach previous inspection records, if any)
❑ .Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 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
68 Prudence Lane
M
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Tank is original to house. Leaching was upgraded in 2005
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grader 3
feet
Material of construction:
❑cast iron ® 40 PVC ❑other(explain):
Distance from private water supply well or suction line: >20feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage._
Septic Tank(locate on site plan)`.
Depth below grade: 2.5
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:
5.2x5.2x8.6
Sludge depth:
6"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
page. Citylrown 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
32"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection tank appeared to be leacking water level was down to the seam.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: x
❑ 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•09/08 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
68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is y required for every Cotuit Ma 02635 8/2/11
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):
I '
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
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.):
At time of inspection d-box appeared to be in good shape no sign of leacka a or carryover.
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.):
w
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 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
68 Prudence Lane
Property Address
Jillian & Mark Gent -
Owner Owner's Name .
information is required for every Cotuit Ma 02635 8/2/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cost.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ 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.):
At time of inspection leaching appeared to be in good shape.no sign of staining or hydraulic
failure.Leaching was dry at time of inspection.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System,Form - Not for Voluntary Assessments
Q° 68 Prudence Lane
4M
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
page. Cityrrown 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: y
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is Cotuit Ma 02635 8/2/11
required for every
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
4 '
2 q '
r32 � zg '
A3
A 3 �1 O
D E C_ (L
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 68 Prudence Lane
Property Address
Jillian & Mark Gent
Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
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 high ground water: >147"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: 8/19/05
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
I
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5iris•09I08 Title 5 Official Inspection Form:Subsurface Sewage •Disposal System Page 16 of 17
P Y 9
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 68 Prudence Lane
Property Address
Jillian & Mark Gent
-Owner Owner's Name
information is required for every Cotuit Ma 02635 8/2/11
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
15
(Sins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal
sal System•Page 17 of 17
l
TOWN OF B/ lStABLE �.
LOCATION G8 a r�x� cncc LrJ SEWAGE # 200 Y(pq
VILLAGE . CCH V i i ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. C;Woy ynn- oGS3
SEPTIC TANK CAPACITY ,/000 Qci/
LEACHING FACILITY: (type) Sno4a1 z1 o",ns (size) x 2
NO.OF BEDROOMS 3
BUILDER OR OWNER Pr-Jr r r oc�5
PERMTTDATE: 8-9S- 05 - - 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
Al
A? 4
gZ
A3 - y
403
A y -
AS- �y
0
ham, r� r
No.ter- -CJ O` ,,i`y Fee f 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
application for Ziopont 6potem Comaruction Verna
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System 0 Individual Components
Lo ti ddress or Lot No. Owner's Name,Address and Tel.No.
� ` �v�EN t� Ct�-Tarr � 21 Cabs SOS'�S3 g'�91
Assessor's ap/Parcel Co m IT
In Caller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. C ��j r
/ ?�-6i V C S -C� JAI 11'�/UC/1 _rAt Da 117"s �l�k 8�,33-�� �7
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other 'I�pe of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date f3 19 0.ti Numbei of sheets P Revision Date
Title 51 T"E +SRU),A6E—P A)
Size of Septic Tank 1000 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this d of Health.
Signe Date IP-6 f 0
Application Approved by Date
Application Disapproved for the following reasons
Permit No. a025 41d- Date Issued
S'
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppYication for 30i9pozar Opotem Cott6truction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ).
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
loe
NO. F2e ��4,/.. _
a ;
' THE COMMONWEALT060'MASSACHUSETTS Entered in computer:
les
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS
01pplication for Zigponf bpgtem.Conotruction Perron
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Locatim ddress or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel pRuo
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. s
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
r Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design.Flow -3 0 gallons per day,. Calculated daily flow gallons.
Plan Date iP) 01 9 10 Number of sheets 1 Revision Date
Title +
Size of Septic Tank 1000 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
F a
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 issued by this�B,oard of Health.
Signed 1 .; Date
Application Approved by �'' L"� Date
Application Disapproved for the following reasons
Permit No. �C)("; ~1 r'�. ! � Date Issued � esa
.. . . . - _. - ,.
THE COMMONWEALTH OF MASSACHUSETTS
'a"
BARNSTABLE, MASSACHUSETTS
t,=
Certificate of Compliance
THIS IS TO�ITII -, that the On-site Sewage DisposalSystem_Constructed(X )Repaired ( )UpgradedAbandoned( ) 1 1 - o\ €I ((1\/n 11, 11 i
at fa `� � 1 «) i ?, 4 has been constructed in a cordance
with the provisions of T,i-tlea5 and the for Disposal System Construction Permit No. .T dated 2S�f ).95
f*Installer b big X C(k tY ri Designer i r ra n.-n.1)1 1
The issuance of this permit hallsnot be construed as a guarantee that the system w'14 ifun,tion as designed.
Date Inspe4r,.
No. f�-(�'�.'�j �.J (_�--------�------------------Fee Jl.,� �
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi.5po!ar *pgtem Cou!5tructiou Permit
Permission is hereby granted-to Construct( )Repair( )Upgrade(,, Abandon( )
System located at 4,)5� o 0 r n c.Cam. V-Q c- e i
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 becompleted within three years of the date/6 this permrt:f
Date: `'°'�/ ! Approved by,—
- giftyti �
`w h'! `^" •, s >s. . •:e as
Town of Barnstable
��pfiHE Tpw '
�. Regulatory Services
Thomas F. Geiler,Director
* .BARNSTABLE. '
MASS' Public Health Division
. s63.9•
AiEoA'�° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Dater
�
Designer: c�:AO>D 6. MA 5� Installer: -
Address: . ,�.1 l_vUIV__ tC2 Q411-1 Address:
On -95-o � � was issued a permit to install.a
(date) - (installer)
septic systemat 1 _ �' )gsed on a design drawn by
(address)
M dated C/ 057
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State& Local Regulations. Plan revision or
certified as-built by designer to follow.
� r
(Installers Si e
k S
I -
si er's Signature) (Affix Desigiier':.s.Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECErVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Desiper Certification Form
9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, hereby certify that the engineered plan signed by me
dated k Z ,concerning the property located at
-?QyQ04Q& 6v� meets. . all .of the
following criteria:
• This failed system is connected to a residential dwelling only. There are.no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or may conduct deep
test holes and percolation tests at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
i The bottom of the proposed leaching facility will be located no less than five feet above the -
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information '5Z+
B) G.W.Elevation +adjustment for high G.W.J? = .
DIFFERENCE BETWEEN A and B .
SIG DATE: 2r-,/
NOTICE
Based upon the above information;a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASepbc\percexernp.doc
THE COMMONWEALTH OF MASSACHUSETTS
" BOAR® OF HEALTH
�. --------------------OF....... ......................................
Appliratio t for llhipaii al Workii Chou.5trurtian, prrutti
Application is hereby made for a Permit to Construct (e ) or Repair ( ) an IfQividuO� ewage Disposal
System at:
........................ . ..---......................4.................... . J ................................. ---- -
Location Address r Lot No.
.:...................................
Owner dres
WN....._. To ------------------------------------------ -- �9 "" u1�_ ... .1.
Installer Address f
U Type of Building Size Lot...ZZt_ P....Sq. feet
Dwelling—No. of Bedrooms........... ..............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons-.--•_______________________ Showers — Cafeteria
Other fixtures
------------------......................................................... a;
.�
W Design Flow................. _<...._..._._._----gallons per person per day. Total daily flow.._..._.._._..___ _.................g�llons.
it
Ix Septic Tank—Liquid capacity) ..gallons Length__ _""--.. Width_4-.�0.. Diameter________________ Depth.5..-V...
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit N ------- iameter.........62...... Depth below inlet.......< ....... Total leaching area. �! ...sq. ft.
Z Other Distribution box ( Dosin tank ( ) _ pa
~' Percolation Test Res is Performed by..l�:_o o.`-`�___._Ck)&:..6:..._(MC—�__._..__... Date...�_.�!®1 p..............
Test Pit No. 1 ___minutes per inch Depth of Test Pit......17Z. ..... Depth to ground water.....::. .............
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
OP.' --------•----------------------••-•------------------------•-•--•-•------•d of o oil-------7-------•- ----•----•---------------------•-----------------�-1---�--- ---
Des i ------ Jam" -------------------------------•-------------
t.,
x -•---•----------------------------------------------------------------------------------•-•-•--•---•-----------------------------------------------------•-----•-•---•----------•-••-••-•-•••••...-•-•--
U Nature of Repairs or Alterations—Answer when applicable._-_________________________________________________•------________._-----•------_------.------.
-•-----------------------------------------•-------------------------------------------•----------------•---•--------------------------•...............................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TTL
p 5 of the State Sanitary Code—The undersigned further agrees not to place the sy tem in
operation until a Certificate of Compliance has been i ued b e of h.
Signed. - . ................ -- . •.-------•... ... .... . ...............
ate
ApplicationApproved By-------------- -`/-�/-- -------•--------•--•----•--------------------- --•------------------------------•------
� Date
Application Disapproved for the following reasons--------------•-----•----•--•---•---•----•----------••-•---•-•--•-------••---•--••----------•-------••-......---
•-------•-•---•-----•------------•-•--------•---------------------------------------------------------------•••--•-••-----••---•------------------•-----•..............................................
Date
PermitNo......................................................... Issued_.......................................................
Date k.,
.......... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ADW44.....................................OF... ......................................
Appliration for Uhipatial Workfi Tomilrurtion Prrutit
Application is hereby made,for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
....................... c ......L!A................................ ...................................LoT.........0-7....................................
Location-Address Z or Lot No.
...... . ......wx"A' ..................................... V..... m f 8
.......... ............�.f ... M,A
Owner
..................................................................... .....
Installer Address
Type of Building Size Lot_-zZj._4P0....Sq. feet
U Bedrooms...........3..............................Expansion Attic ( )Dwelling—No. of Bedro Garbage Grinder
P4 Other—Type of Building ............................ No. of persons....._._____......_......... Showers Cafeteria
04
Other fixtures ---------------------------------------------------------------_---_--
-------------- ----------------------- --*-------------*-------------- - S Design Flow.................S<..................gallons per person Ner day. Total daily flow................... ..39..............X.ll.ns.
P4 Septic Tank—Liquid capacity-IOCO..gallons Length..!F.1�".. Width.4_'J_Q.". Diameter______I......... Depth.5'_-.A....
Disposal Trench—No................ Width...._.........._.... Total Length.................... Total leaching'a'rea....................sq. ft.
0 Seepage Pit No.___--_____ -------- iameter.........6...... Depth below inlet.......<!�....... Total leaching area.:�4�Pt...sq. f t
Z Other Distribution box ( ;e Dosing tank )
Percolation Test Re is Performed ......(.W.0............. Date... ..............
........... ........ . ....... ......
Test Pit No. I ---minutes per inch Depth of Test Pit...... .....1._Z� Depth to ground water-__-_<� ---------------- -P� Test Pit No. 2................minutes per inch Depth of Test Pit.______........._... Depth to ground water.________.._............
P1 .......................................................... .......
............. -- '-:------------------ ----------
C71P IT 0 01 Y-----X4-------- .. ... ....... ... ..................................................
0 D es f Soil.......
U ------ .......Q_.). ....... ........................................................................................
...................... ..................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TTL, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued bythe b rd)of,hea,1th.
Signe ......................... ............
................ . 4
7 /bate
ApplicationApproved By.............. ...... .. . . . . . . ......................................... . ........................................
Date
Application Disapproved for the following reasons:.. ..7 ..................................................................................................
........................................................................................................................................................................................................
Date
Permit No..................
.. Issued. .....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
........... F........A.A M
QW. ...... ..A&. ..............................
(9 ifiratr of Toutpliattrr
THIS (CERTIFY h3.. ndividual Sewage Disposal System constructed or Repaired
by.............. .... .......................... .......P 7j--- ...........................
Installz(-/
at................ . ...... ...... -7-------- ------ ------7_11 ---- _---------- ----- _--------------
has been installed in accordance with the provisions of TIT 1Z 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_________________________________________ dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISf-iCTORY.
DATE4 ' .)..—.... j
......................# 7........ Inspector............ .
....A...............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.............J...................................................................
No.------14V........ FEE........................
Disposal
Permissionis hereby granted.........LTe h,"-.........!�t.f.4nt.............................................................................................
to Construct ( 7() or Repair an Individual Sewage Dis osal System
atNo---------------- .......... Of .........................................----.....--._--
Street
'X rz;'
as shown on the application for Disposal Works Construction Permit, No,------/....4---C_�---- Dated........A/...............................
..........*-/&-e.................................
----------- ............
.... ..... ................................. Board of Health
DATE._
FORM 1255 HOBBS & WARREN. INC., PUBLI791HERS
���lG►� Tj,6,TA
F'Low - 110 4 3 t 33o G.RD
SE�i-!G T�ilC - 33o,. iSo % * 4-95 ��
USA- t OOC� GAL. -
1
415P05AL PtT - t.)SE logo G
SMSUALL AZEa = cso s.t=.
low S� � 2.S • r'7�j G.P.T7. Z4 �I i
FOT-MAA AOSA c r,,Q ST-. MXN
,ZO �jllr/
So 65:7. f 1 .p SCE s.PV. f7+T l 1
TOTAL -L7ESl6Kl = 4ZS
ToTOL -dal L-f FLow = 33o b.P.D.
PMOC-OL4,TioO tF&TE : 1"tu 2-M!W' O¢
�� �Y� ,� tit � .i•, �• i� �
TarPoc oo.o
Lx
t •Poe ':Y ,uv q7.o
t oco i�
Svsscx�. 4'Pp� tw. G o�. 14&.8 ;.
l•5 'sox �� Sic lc .
_ t7V-
C-TANK
f000 IV.GAL. ("7. Q&4
LANPoTa � SZTIFICC7 PL(::>-r PL-,A, .3
PRA�'tL_� LOGAT101-1 G,GT) Ir
wo S CAL ��3f loo
" FcrS
GGt`Z-•C11 ,{ Ti4A-r TN �Pt �l' '�IC7l�J 5taowl.! PLAi.l R i* Rc:�.1t
%4Z:L=msJ CC)vVkPLVG �+V 1TN T►-Ir: 51Dt�.Ll►-�E: J g-�
A► I:D SE-roAC4 ;7C-QUjCEAAE-W` ,; OP T1 F-- �t
-Toww ov- SAfzOe7TAf5i-tz.,
DATE
-tl-its hLAW' t-S LJOT M-A-SMV
IW�, JM t.IT <,uc�v� • T!{L: c�F'4^",�T�, 5�1a�tn APPt-I
+,Ur BraU�',Gc Tot�+'1 Gi~'M►yJL L[a"C' t�!NC:�� - fl,. ,, ;,)M(,-T'rr
LO CATION � (UU SEWAGE PERMIT NO.
j��.2�9 C+P h�d"P / �oLLyif �ry•z s�so�i3�
VILLAGE
co '
INSTA LLER'S NAME i ADDRESS
JOHN A. AALTO BACKHOESERVICE
150 Walnut Street
West Barnstable. Mass 0266
U I l D E R �OR OWNER
fed /3oa yi F Gl/�s�` l�yg�h.'f
DATE PERMIT ISSUED 41_2 9-e2
DAT E C 0 M P L I A H C E ISSUED s
,P�7t off• �de
-10
o . 137/ �+
/9lvH !�/ll6I�
2 ASSESSORS MAP: ?�
TEST HOLE LOGS
PARCEL: NOTES:
WITNESS: Nam
PERCOLATION RATE:L -,?,IAA_-
FLOOD ZONE: _ -A/CT �3i�f-� _ SO L EVALU••A- JOR:�L� ► N/� -
_ ,
REFERENCE: = ���c �l C r DATE: l3
1) The installation shall comply with Title V and Town of Barnstable Board of
, �
Health Regulations.
�► 157117 2) The installer shall verify the location of utilities, sewer inverts and septic
TH- I TH-2 components prior to installation and setting base elevations.
LOH�1� t 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.
� !d 4) This plan is not to be utilized for property line determination nor any other
IVRWI 6(4A4f___) , purpose other than the proposed system installation.
5) All septic components must meet Title V specifications.
> ' 6) Parking shall not be constructed over HI septic components.
LOCATION MAP
C :J '" 7) The property is bounded by property corners and property lines.
4t — 8) The property owner shall review design considerations to approve of total
design flow and number of bedrooms to be considered for design. Receipt of
✓"' payment for the plan and installation based on the plan shall be deemed
~' ,• ': �lo approval of the design flow by the owner_
9 The existing leachpit(s) shall be pumped and filled with material per Title V
� �,� ) g P P
I abandonment procedures. Those within the proposed SAS shall be removed
v along with contaminated soil and replaced with clean washed sand per Title V• U�('1YG
-- specs.
10)System components to be 10 feet from water line.
11) If a garbage grinder exists it is to be removed and is the responsibility of the
S E P T I SYSTEM DESIGN owner to ensure such.
FLOW ESTIMATE
�Lh i
BEDROOMS AT L GAL/DAY/BEDROOM •? GAL/D Y
15 S
L ---
?�CaL/DAY x 2 DAYS -
GAL
USE 100 GALLON SEPTIC ANK
MW
o � ;U , �
B I ON SYSTEM
SIDE AREA: k -F l X 1C _4
r V -i bOTTOM AREA:
l �
EPT I a�: SYSTEM SECTION
5b 'Z , 7 Z mar 3 ,, �wc
► D-Box SO
-�
GAL ►D o "n.,SEPTIC TANK
U �.� �1USi1WC� ✓' `� z
5
FLOCASITE AND SEWAGE PLAN
T1
I ON : 2t 'LAI. �-
PREPARED FOR : t2peor, L,P
.n WA
M
O
& SCALE: = 3O
lu
DAV I D B . MASON R DATE: I�
j DBC ENV I RONMENYAL DESIGNS
2
DATE HEALTH AGENT EAST SANDWICH . MA
_ ( 508 ) 833-2I77
"
Large Format
Box #
Doc # E
Image #
I M A-�G(Z�E
DATA