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HomeMy WebLinkAbout0044 QUEEN ANNE LANE - Health 44 QUEEN ANNE LANE COTU IT A= 022- 120 I i Commonwealth of Massachusetts oao2 - a.o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 44 Queen Anne Lane Property Address Nancy Leclair ' Owner Owner's Nam information is required for every Cotuit 1 MA 02635 08/03/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. i Important:out forms A. Inspector Information filling out forms on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return key. Company Name 52 Rivers End Road Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 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); I 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 08/03/2020 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit - MA 02635 08/03/2020 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: I 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is Cotuit MA 02635 08/03/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ® Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 page. Citylrown 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: The H-10 D-Box is leaking and has exposed aggregate. 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 1 c Commonwealth of Massachusetts �v ,g Title 5 Official Inspection Form i1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is Cotuit MA 02635 08/03/2020 required for every 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 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® q P p 9 Y 99 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. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 page. Cityrrown 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 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts ,o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 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): GPD lus Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 years usage d town water Detail: In the first half of 2020-72,000 gallons were used and in 2019-160,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: 10 days agoDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Queen Anne Lane u Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Rp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): water was flushed and it came freely t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 24" 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: H-10 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? 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.): recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the baffle was in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 cam, Commonwealth of Massachusetts �v Title 5 Official Inspection Form I? l�� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is Cotuit MA 02635 08/03/2020 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 ❑ 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Il; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Queen Anne Lane V� Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No 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.): The H-10 D-Box is leaking and has exposed aggregate. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection p Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts g� Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 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 and appurtenances, etc. pumps pP :) * 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: One ❑ leaching chambers number: ❑ 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 Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Queen Anne Lane V� Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ire Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.). 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Queen Anne Lane Property Address Nancy Leclair Owner Owners Name information is required for every COtUIt MA 02635 08/03/2020 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 **As-Built from the installer attached on next page** I i t5insp.do6•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 'Assessing As-Built Cards https://townofbamstable.us/Departments/Assessing/Property_Valu... ,ply 9�' LOCATION SE AGE PERMIT NO. VILLAGE INSTALLEIt' NA iZ ADDRESS BUILDER/ OR 1OV11100 Asb oWNUe_ ---fi t C0,6oL te,'s GATE PERMIT ISSUED DATE COMPLIANCE ISSUED Le GK .9 d 1 of 1 8/2/2020, 10:29 AM Commonwealth of Massachusetts Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feetfeet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit. 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 Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�%% 44 Queen Anne Lane Property Address Nancy Leclair Owner Owner's Name information is required for every Cotuit MA 02635 08/03/2020 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 I N _20Fee— ? THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Disposal *pStrm Cunstruttiun Permit Application for a Permit to Construct( ) Repair(✓) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2 2 120 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Y�, 4ke[q /44nn.e I q r.—e Installer's Name,Address,and Tel.No. 916'�i° " Designer's Name,Address,and Tel.No. O` -6 U,0^4 �� tJpry; Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. G Description of Soil Nature of Repairs or Alterations(Answer when applicable) ce— 7-� Date last inspected: &n L �� 0 a 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 Co not to eration until a Certificate of Compliance has been issued by this Board of He Signed Date �^ 2^ 01 Application Approved by Date Application Disapproved by — Date for the following reasons Permit No. J Date Issued .n., �:.,,h+i r...'s �..^�n..,:. ...r:;.+-,.F . _-.,..__;, ...-e�F. ice, ram. .. q•x,; :�.• ,r' . Fee ✓ / THE COMMONWEALTH OF-MASSACHUSETTS Entered in computer: y PUBLIC HEALTH DIVISION -VTOWN OF,BARNSTABLE, MASSACHUSETTS Yes application for MisposaY Opstem Construction Permit Application for a Permit to Construct( ) Repair pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 170 c tf 7_ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel, YfK.atkc ell! +q e 4 r ,rw G Installer's Name,Address,and Tel.No. �S� XC� " Designer'''Name,Address;and Tel.No. r (�^qJ s tr f of Type of Building: >q. .." Jf tw 1 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) t 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 SAS. ' • ' Description of Soil if } x, - Aee ,/ter Nature of Repairs orAlterations(Answer when applicable)' t /�: .? ' Date last inspected: J&'IC. Agreement The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in - r; accordance with the provisions"of,Title 5 of the Environmental Co e and— p, cesth Yste xin�op ation until a Certificate of Compliance has been issued b this Board of Healt P Y .. Sig ned Date O f' ► r v Application Approved by Date CS Application Disapproved by ;, .`. —._ . Date for the following reasons ' Permit No. """ Date Issued ( 1 l r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTI Y,that the On-site Sewage Disposal s stem Constructed( ) Repaired Upgraded( ) Abandoned( )by e/ � Pe _ tat ,+ has been cons tructed in accordance with the provisions.of Title 5 and the for Disposal System Construction Permit Now EZAdated ( -� Installer, IhrK,4,6-e w+ .` Designer r #bedrooms Approved design flow .! '� and The issuance of this permit shall not be construed asa guarantee that the system<i 1 f'unc to =as des ghed. Date ( Inspector c, ----- Ni f — -Feed THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal 6pste -Construction 3permit P fission is hereby granted to Construct( )" Repair( ") Upgrade( ) + Abandon( ) System located at /? and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions } Provided:Construction must be completed within three years of the date of this,permit. Date Approved by LOCATION SEWAGE PERMIT NO. -� c-f maw-/.:?-U VILLAGE INSTA LLER',S A E i ADDRESS D BUILDER OR 4WWW Mb DATE PERMIT ISSUED _ DAT E COMPLIANCE ISSUED L­7L- 1 ' No.t ---.-.-y .. Fm3:7. ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ..............oir......... Appiiration for Disposal Works Tonstrnrtiun rprMit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................Q�tk! b ...t iv�I ,- '4! L........ ur � rNl ..:_�5 �1:-.. ..... ........................... Location-Addres or Lot No. 7 T7..... k4lC. .... ........... .........w,�Q.Kjal.--....1`.Q:--------------------------- ........ W __-Owner Address�' h [Q9� '17. t ---------------------------------- --------- A l t�� PlLk .............................................. M Installer Address Q7i Type of Building Size Lot..... _ ra0.......Sq. feet U Dwelling—No. of Bedrooms............3................ .Expansion Attic ( ) Garbage Grinder 4-18 a Other—Type of Building No. of persons............................ Showers — C4 YP g ---------------------------- p ( )-------Cafeteria ( ) a' Other fixtures . w Design Flow____________________ _.___..___.___.gallons per person per day. Total daily flew.._.___._.___. _ .___..._._____ga�lons. WSeptic Tank—Liquid capacity.[0CC-).gallons Length__-6-.... Width.A.-_l o Diameter................ Depth..' x Disposal Trench—No..................... Width ....... Total Length............. Total leaching area___-C ------- ft. Seepage Pit No.....I.............. Diameter.......9.......... Depth below inlet............... Total leaching area..................sq. ft. Z Other Distribution box (L Dosing tank ( �.�_ aPercolation Test Results Performed by_____________________R- .110... ...��,'�° _�__�__...... Date...._._......... _._ ' Test Pit No. 1.4�......L..minutes per inch Depth of Test Pit------ ...... Depth to ground water_.C 99.E -_-1--tj Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... R+' ........................................._._.......................•.............................................................. ........-........ 0 Description of Soil................................................................................................................................................................. x U .........•-••••----•-•.....•-------------------------•-•-------•----•-•---••-•••----------•....•---------.....-•----------------....--•-••----•-----•----------------------------•-•-•••-----•---------- w 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue e boar of he�,lt Signed. ...._.. �'�r�c -.......'. ---------------------- Application Approved By-, r � ------------- •------------------................................. ate-------------- . -� Date Application Disapproved for a following reasons---------------------------------------------------------------------------------------......................... ................................................................•....................................... Date � _ �P7,ermit No.------•--------•------------------------•--------------. Issued.--•------------•---•-------•-------•---•---•----------- W Date NoP':.�. a...... Fss .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - Cw + ...............OF....... ..... A 5. KkE..................................... Appliration for Disposal Works Tonstrnrtiun rantit Application is hereby made for a Permit to Construct (Y) or Repair ( ) an Individual Sewage Disposal System at: kA .......• `� - -.... ._..._... ......••• .. ........... ........................... ....._.... -•--•- . Location• ddr o Lot No ........ ........ X.. ...... ............ W A `fe .b ! „fd, - f drjess a _.. Installer Address Type of Building Size Lot_-- _k©g_.......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria aOther 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 W --••••----•-----•-----------••-•--••--------•----------------••••--•-•-•-•----------•-••-•-•--••--•-•......-•-•-• ............................................................................... UNature 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 TIT1Z- 5 of the State Sanitary Code— The undersigned further a ees not to place the system in operation until a Certificate of Compliance has been is4-ugaAoy,1he boarpl of hwft . f 11/Z Signed.......... ........................---(�f-•------•-----------•---•-----•-- 1 ., Application Approved By.. . Date ----- PP PP Date Application Disapproved or the following reasons:.............................................................................................................. - ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........�..v...w .............OF........�-�. 1 5 i6 .A................................... (9rdifiratr of TompliFanrr THIS IS TO ERTIF—Y, That theIndividual Sewage Disposal System constructed (<) or Repaired ( ) b ! � cl� e Y......_..... , Installer �q .�..r. at r-------•�I�� I.................... ....�nl...l�.-•-•- ...•-----------------------------------------•-•------......--•------------------ has been installed in accordance with the provisions of TITLE _r of The State Sanitary C de s described in the application for Disposal Works Construction Permit Ncki�-•%�`--------------_--------- dated _ '.......................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................... ........... Inspector-----------------r,.A '. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...�.�. ............OF........... ��! r 7�6��,................................... ell- No....................... FEE..3.J.............. Dispo 1 k n�trudilan rrnti# Permission is hereby granted -- ................................................... to Construct O r Rep ( ) an individual Se r e Disposal Syst -at No._�jn7' ._. •..... l�S. •----'�g----------------- - ------ �^. 11 ---•---- ----••---•---•--- Street _ � as shown on the application for Disposal Works Construction Permit No._f ^.fC.... Dated-3_.._..�_ "_!�'". ................................. -�------------------------•-----------••-----•---•--- DATE. �j -�. ...____ Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS SLk:1Gl.� 1rMntt.•�( - 38> veo��M � "� u � .•.. . --t �. Ub GArzuAGE •6•tZI 1,lt✓ER 2>&tt•-.( t=L.ow Z. tic) W. 3•s 330 G•Pv { , : :.. usV- t000AM S�I�POaAL_ PtT .�t�S� Ip� Gd�. •� f : . : ' � • - IC,-p 5F at 6-9-U. t i TOTAL V70u t !-roTnL �att_�f 1=Low z 3.3p 6.P.•D. .►,� C /f f� C •.flGE>"T1O1.1 tZkTE S IN SMi u•oz l 5 61 Z. rr 0 Vp � y ?eTWL�►J �. VT. ray .+,G� .. Tor Fero .' - P•g 7.1 4 1 4 O�� 39;0 • S(43uIL. ... 4'' nrsr RN. GAL- -eo sepnc Io H 14V. � TANK I q d;Al.. u FT � C��TtF1ED PL.oT Pt_.t1�..1' LOGATIM-4 �L.A►..1 jL��`�E►.1GE � GGaTt�� 7�-tAT Tlac-.GU�G�.�U►J�.S��v►J • fr-1C:Q L'-ct,3 GcaMt'L�lS W 1 TA TO;Z: 51 V E:- t_l WG-- L-C1T•. Aug •SC`i'L-AuC jrGQUiVEMcuTS of THE: '[o W u OI= AUt) IS v v T- �'E:-PC►� .RGr� "L-1 t LOGATEb• Will-tIL4 TW1~ K'L.Ot>r-) P1-�►14.1. c�aTF- 2 ,25 y2 n Q)(Tc91 r t2EGtS*rc--RED "Wo Nueva orz `�'1-{15 t7�A►-I i r.. U OT LA5 C[7 11-I AN oSTECvtL�.G a IbtAS�„ o4gr�'J/✓tl:%.IT* ��UI`.It=�( 'tldL UFt., _T�. �1IGwLI� API�LI