HomeMy WebLinkAbout0014 RIDGE TOP ROAD - Health 14- Ridge Top Road
Cotuit P
027 143
43 _7
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r e r,
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441) .
Owner Owner's Name `
information is
required for every Cotuit MA 02635 1-17-19 .
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.
A. Inspector Information
Shawn Mcelroy
Name of Inspector '
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA - 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that] 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 theproperty 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
1-17-19
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/M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
s Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
+ i► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441) .
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
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 El ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
page. City/Town State Zip Code Date of Inspection
C. Ins
pection ection Summa
rYCont.
2 System
m Conditional) Passes cont. : ,
Y Y
❑ 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):
❑Y broken pipe(s) are replaced 1❑YY ON ❑ 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 inorder 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
tie Commonwealth of Massachusetts
7 ,. Title 5 Official Inspection Form
' i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is Cotuit MA 02635 1-17-19
required for every -
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines.that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
colifofm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® ' Backup of sewage into facility or system'component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts f t
1� Title 5 Official Inspection Form
�.1'
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:r. „/e>°J 14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real,Estate 1-800-966=2441) f
Owner Owner's Name
information is required for every .Cotuit MA 02635 1- 7-19 . ,
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No <f
El ® Static liquid level in the-distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS; cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or.privy is within a Zone 1 of a public water supply
well.
'❑ '® 'Any portion of a cesspool or privy,is within 50 feet of a private water supply well.
❑ ® Any portion da 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.
® i 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), Lar e S stems:To be considered a large system the,system
stem must serve a facilitywith a design
9 Y 9 Y y 9
flow of 10,000 gpd to 16,000 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
ty Title 5 Official Inspection Form
R,ai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each,of the following for all inspections:
Yes No r
❑ ® 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,
r
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Wasthe 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
3, Title 5 Official Inspection Form
bl Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flowbased on 310 CMR 15.203 (for.example: 110 gpd x#of bedrooms): 440
Description:
y ,
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 El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter"readings, if available (last 2 years usage (gpd)):
Detail:
t
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
s
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
N i-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V f`
�. 14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
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 MR 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: N/A
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 _
Title 5 Official Inspection Form
iP Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t 4:
r ,r,
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441):•,
Owner Owner's Name ,
information is required for every Cotuit MA 02635 1-17-19
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
❑ t -Tight tank.Attach a copy of the DEP approval:•. ,
❑ Other(describe): t,
Approximate age of all components, date installed (if known) and source of information:
1987 r
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan): <,
Depth below g 54"rade: 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.):
Good condition.
t5insp.doc-rev.7/2612018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
Title 5 Official, Inspection Form
'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information cont. '
Y (cont.)
6. Septic Tank(locate on site plan):
Depth below grade:
' 48"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other ex lain
g (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with bafffles installed and no sign of leakage.
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.
ill Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments
14 Ridge To Rd
P
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
page. Cityrrown 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
cam, Commonwealth of Massachusetts
�l Title 5 Official Inspection Form
i�l'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
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.):
Good condition with water at working level and no sign of back-up from pits.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form!Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i MI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - ,.
r ,
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate,1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan): t
Pumps in working order:' ❑ Yes ❑ No*
Alarms in working order: ❑ Yes, ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass. -
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type: t .
® leaching pit's 'number: 2-600 Gal
❑ 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/M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts .,..
w Title 5 Official Inspection Form,
h. ,ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . .
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
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.):
Both leach pits were empty and in good working order at inspection. Pit marked "5" had no stain lines
and pit"4" had stain lines at 6" below inlet invert.
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
,Y?�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>" 14 Ridge Top Rd f
Property Address
Bank Owned (Contact David-Holt @ Today.Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19 .°
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) _.
13. Privy (locate on.site plan): "f
Materials of construction: '
Dimensions
Depth of solids 1
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
S
f
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts '
,w Title 5 Official Inspection Forme .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is Cotuit MA 02635 1-17-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System: .
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below: `
® hand-sketch in the area below
❑ drawing attached separately
4:
— /
r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
4.
/ Title 5 Official Inspection Form .
r�l Subsurface Sewage Disposal.System Form -Not.for Voluntary Assessments_
Z.
14 Ridge Top Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
page. City/Town 'State Zip Code Date of Inspection
D. System Information (cont.) k -
15. Site Exam:
❑ Check Slope
❑ Surface water ,
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground.water:,. 20'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed Date
® . Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
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 -
w Title 5 Official Inspection Form
i-�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� rtM 14 Ridge To Rd
T, l g P
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2441)
Owner Owner's Name
information is required for every Cotuit MA 02635 1-17-19
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
i
t5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
?Ab-1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
41.4P .-
ARCE ; SEP 0 1 2004
.Q .b TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 14 Ridge Top Road
Cotuit, MA 02635
Owner's Name: Ken Raymond
k
Owner's Address:
�a
Date of Inspection: Aueust 16, 2004
Name of Inspector: (Please Print) James M. Ford a'
Company Name: James M. Ford '
Mailing Address: P.O. Box 49 ZK v)
Osterville MA 02655-0049 i
Telephone Number: (508) 862-9400 �—
r ri
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
• Needs er Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: August 19, 2004
The system inspector shall sub 't copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completin 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1 --
i
Page 2 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: August 16, 2004
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.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with 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.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
I
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: August 16, 2004
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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: Augmt 16, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow
✓ 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 I of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes"in Section D above the large system 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.
0 . The system owner should contact the appropriate regional office of the Department.
4
• Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: August 16, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ _ Were as built plans of the system obtained and examined?(if they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
v' 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:
Yes No
✓ _ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: August 16, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no): .
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 3 years ago-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed in 1987-per owner
Were sewage odors detected when arriving at the site(yes or no): No
6
• Page 7 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: A_uzust 16, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 4'
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 yal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring 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.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage
The inlet and outlet covers had risers and were 10"below grade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: August 16, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: August 16, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-4'x 6'w/1'stone(per design plans)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
The liquid in one leach pit(43)was up to the inlet pipe. The bottom to juade was 9'and the cover was 6"below grade The other
pit 04)was dry and clean. The scum line was approximately 6"up from the bottom The cover was 15"below trade There did
not appear to be any signs offailure.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: August 16, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
A LS A 8 5,—)^1 rS �k
13
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10
Page 11 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 14 Ridge Top Road
Cotuit, MA
Owner: Ken Raymond
Date of Inspection: August 16, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30 +/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
AccessedUSGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic maps and water contours maps the maps were showing approximately 30'+/-to ground water at
this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees,either expressed, written or implied, relating to the system, the inspection and/or this report.
11
ASSESSORS MAP NO- _ � �--
PARCEL NO.: ate" �� u
F�s....��-....
THE COMMONWEALTH OF MASSACHUSETTS
-- 7 BOARD OF HEALTH
i - �� & '. ------..........oF....... .....................................
Applira#ion for Bispuiittl lflarkii .Tnnitxnrtiun lbrmit
Application is hereby made for a"Permit to Construct (Zor Repair ( ) an Individual Sewage Disposal
tem at 4
pip
ocati Address or Ut No.
......................... --•... , : .-...----••-•------• -•........---•-------------....._.__..------...............-------•----•-----------------------
Owner Address
. A-0 (-L c-4.
a ......................................................---••.............••......---•-------•-•-•- •----•-•-•---••-•---------------••-------•------...........-•-•-••----•-----•--••-•------------••.
Installer Address ]
d Type of Building / Size Lot_. _` P......Sq. feet
U Dwelling—No. of Bedrooms.............vi--__•••-_.____•--.______--Expansion Attica ) Garbage Grinder &Q
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ..................................
W Design Flow......................��++--•--_--•---gallons per person per day. Total daily flow....................... .........gallons.
C4 Septic Tank—Liquid capacityb _-gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No. ............:....... Width.................... Total Length_.____......'____.__ Total leaching area--------------------sq. ft.
Seepage Pit No........... iameter...... ------- Depth below inlet......'......... Total leaching area.& a...sq. ft.
Z Other Distribution box ( � Dosing tank( )
Percolation Test Results Performed by zA _---..Vp '........P-.J.S0 .-... Date........................................
Y
Test Pit No. 1_... ^---minutes per inch Depth of Test Pit...... Depth to ground water...""'-..........
."
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
-----------------------------------------------------------•--......--------•--.......-•----------•.........................................................
0 Description of Soil........................... ...--••---•....._._..._......
x ._...--•-•••-•••--••-••............... �........ PA.0.. AA1 ----- -----------------------------------------------------------
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'TT y g g p y
5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the boa.d of health.
Signed._ . '.!te?!r' _ �
,0 Dale
Application Approved By � p
Application Disapproved for the f ollowin reasons__________________________________
----------------------------•-.......................... Date••--..........
...---•--------------------------------------------------------•-•------------•-•----•-----.....-•----...._...........---•---•----------------------------------•-----------------•-•---•---•-•----------
Date
PermitNo.......................................................- Issued....................................................... --
---—-- _ — Date
No................ a'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Applirtttion for Uhiposttl Worko Totulrttrtiott ramit
Application is hereby made for a Permit to Construct (t, ) or Repair ( ) an Individual Sewage Disposal
System at: ! Lvrd
....................... 1:L11�......20" i ,�..: -- -•----........------------................
Locat n-Address or Lot No.
- '• I 1A_
Owner Address
W
Installer Address
UType of Building -� Size Lot-_ ;.9!Q------•Sq. feet
I—I Dwelling—No. of Bedrooms........... Atti/(� ) - Garbage Grinder N( u)
a`4 Other—T e of Building No. of persons............................ Showers
YP g ---------------------------• P ( ) •— Cafeteria ( )
Otherfixtures .----•-------•-----------------•---•--•---------------.....-----------------------------------------------...........
W Design Flow..................... ...............gallons per person per day. Total daily flow......................t D........gallons.
WSeptic Tank—Liquid capacit�...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 leachingarea/�ZZ..s ft.
Z Other Distribution box (1/� Dosing tank ( )
Percolation Test Results Performed by �I t$ 4 ;-__ T :---__---�••_ ____ Date________________________________________
,a Test Pit No. L_._" ____minutes per inch Depth of Test Pit...... . --!.... Depth to ground water._,.--___---•--__.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_--_____•_-_---_-____
0+ ---•-••••••-----------------••-•-••-••••--••-•••••••-•....••--•--•---........_..._..•--•.._..................................................................
DDescription of Soil...........................--h-----•-•----•-----.....---..........---•--....-•-------------•- --- ------------------------------------------------------------......
. ----------•-----------------------------------------------------
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 T y T's-,
p 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 by the board of health.
Signed......................................................................................
Date
Application Approved BY1 •.. -••-----
E(� f -------•---------•-----------------------
-----y
Application Disapproved for the f ollowa reasons---------------••-•--------------------------------------------•-•--------------•----......•-••-•-•--......_...--
.........••-----•••••---•-----•-•-----•---••-•-•-------•------••--••••••.....•••--•---.......•---•-••--•-•-••------------•--•••••-•-•-••------•--•----•-•-•••-•-•••-•-•--•----•-•-•-- •.- --------------
Date
PermitNo......................................................... Issued_........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
N\... oF....... -N L_v........................
C�rrtifirttte of fauttt�rlittttr�e
THIS LVOUERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
by...._._..- `' e .................•. •-------••----...•............----------•---------•--......------------...------•--•------••......•.
_ / ' Installer
has been installed in accordance with the provisions of TiTIZ j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No... '{,_- __E}.-_---__-__-•---- dated------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................. J_ 8-�$�-------------••-••... Inspector..4 ---DA-�---------------------------•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�� �/ ' ..................:..................oF............ --... .......... -----.. .-------•.----.....................----. J
iV'0...._......••.. ...... FEEL......:.........•••.
Disposal Works 1011,11uBtrurtion ranfit
Permission is hereby granted_.._..... .....-. "�
to Construct ) or Repair on Individual Sewage Disposal System
street •
as shown on the application for Disposal Works Construction Permit Dat ..... .•............
1F -Ev=
rand of Health
DATE----�- -------------•----/---=-----------------------•----••-•-----------•
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BAXTER
No.24048
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A, :�E>-% ':�GUIDE LINE 10 8641I, -
0 t0 X 10 TO THE INCH -
TORN Or.IBAIiNS7' LE
LOCA 'IQI�t
ll14 a SEWAGB:#7677777
194STAI.Lh?R`§: tA99 ctk PHONE No
S131�!'iC TAfiIK CAPACITY ` ('
I�ACfIiNG FA. f5 - (sire)
NO "OFBBl300I�iS:
BUILDER OR O� R
PERMTDATE CC}1V�Lfl�NCE'DATE:'
Separation Distance Betweene Feat
MaxumAdjusted GmundwaterTableto theBotlom of LsachutgFac�tity
pmaie'�Tater Supply�nli atdLeaching Farahit�t (dfany'��ITs exist
on seta ar. n?Ao feet df Iea�ungal
Fcet-
Edge o£V'l and end Leaching FaalttY(If`My wetlands xis
Feet
vnttiist 3(IU Ceeet a :leaching fad) / �:
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1
T6 PWN OF BARNSTABLE
LOCATION 1 SEWAGE #
C'o j//
VILLAGE �- �/ /[ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. 5 (.41_ 47, 7
SEPTIC TANK CAPACIT 4
LEACHING FACILITY:(type) size) ® O 61 �$
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 2g 6jae
BUILDER OR OWNER E t) R t ` kyl b At t�
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �/'
1 1
TOWN OF BARNSTABLE
w L�CATIO SEWAGE #" (
�r/l/�s ��,to y r o�7/
VILLAGE �,, °, SESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. eel/ l.�r/ S�a�/��z
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:SEPTIC TANK CAPACITY Z,�tO® A/ 1
LEACHING FACILITY:(type) loge @ S)' (size) d d q"9 I
NO. OF BEDROOMS y PRIVATE WELL OR PUBLIC WATER vd/G
BUILDER OR OWNER wed 9,4vma.ml>
DATE PERMIT ISSUED:
DATE .C0UPLIANCE ISSUED:
VARIANCE GRANTED: Yes No t/'�
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Q TOWN OF BARNSTABLE
LOCATION �: SEWAGE #
VILLAGE t °tU ASSESSOR'S MAP & LOT®�L�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY l S�
LEACHING FACILITY: (type) �X�� (Gy (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching_facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by1 S J
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