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Home My WebLink About0230 SANTUIT ROAD - Health 230 SAIYTuir, ®COTUIT A=020 �t' u { +I i �j. t�. i I ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments z!' i r.7 230 Santuit Rd Property Address Maher Owner Owner's Na"� information is required for every Cotuit 7 Ma 02635 7/31/2020 page. City/Town State Zip Code Date of Inspection a Inspection results must be submitted on this form. Inspection forms•may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Chad Hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. 6 Company Address Forestdale Ma 02644 City/Town State Zip Code rE� 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage-disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection i have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/31/2020 Inspector's Sig re Date The system inspector shall sub It a copy his inspection report to the Approving Authority(Board of Health or DEP)within 30 da s o pleting 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 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: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don'ts can be found at town health dept or mass.gov 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 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 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 0 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 230 Santuit Rd Property Address Maher -Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 page. City/Town "State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must,indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I — Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .. 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No 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'/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 of a cesspool or privy is less than 100 feet but greater than 50 feet. from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is Cotuit Ma 02635 7/31/2020 required for every 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 f Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): no design Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 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 [D No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 page. CityTTown 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: owner pumped 2 years ago 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 page. Citylrown 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: age of house 1973 unknown age of septic Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.75'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 24+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of leaks or poor venting t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name r information is required for every Cotuit Ma 02635 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H10 1000 gal tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No I Dimensions: 8'6"x5' Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 26" ' Scum thickness less then 1" 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 18" How were dimensions determined? tape and 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.): tees in place. no major decay visable. level of tank is at bottom of outlet pipe. pump tank every 3 years under normal use t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts l? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 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 I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 page. Cityrrown 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.): I ' I , *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 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.): no Dbox t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 L Commonwealth of Massachusetts �n Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 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 pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information. (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 6'x6' precast pit 2 feet of water in pit at time of inspection clean sidewalls over current level. pit in good shape 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 cam, Commonwealth of Massachusetts h4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information required for every Cotuit Ma 02635 7/31/2020 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 Commonwealth of Massachusetts Title 5 Official Inspection Form �- USubsurface Sewage Disposal System Form -Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 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 a" Ho I., 3 sAas'— roor peek t- oa A3 -a C� 1 - avi 63 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 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: 26 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: town GIS Mapping You must describe how you established the high ground water elevation: lot el. over Leaching pit. el. 32 bottom of pit el. 24' low wetlands behind property el. 6'clearing greater then 4'from bottom of SAS to ground water Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 A Commonwealth of Massachusetts Title 5 Official Inspection Form j' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 230 Santuit Rd Property Address Maher Owner Owner's Name information is required for every Cotuit Ma 02635 7/31/2020 page. Citylrown 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 L 40 7 Q w0C:, - z pq V)WN 12 ;M17M EONS15 IIv.LCNI li LA% EOf lII AEMi Fi EE(XING E fWI.N:( in YE EtifPL�JA".iEEEI:3) EYJ51. FI?5f Ftll'k 1 ?y� l�fl1(f''X/NCE`.h fIOX IW.b.G v.1.P0Ai Q U L—J L—J LI U U _- r_rrx:il'•}risr:ES I\l�/-U\ ��vAr10N Li.NI.Ri?'C it'N! ft%I.lif;IlEuSIPL \IIV AY C.I il'..E`.i:Illy, (SCLG: .. SO J Ida•= I'-0* DATE: ;• ' 6.Fs.?Oifs II/6/2000 � I?IGN1 5b� �LFVMIOM .,(�, 4 FOR NO.: XX II II n Jc MAhIER DRAWING NO.: A2 i% . ,; ,�;:•: ., '� rO i�u-t11:GV, if I.P.VYJ?RSF Pa CLPU LVkyV(NJ58170i k5 YJ/I.4 ffaA'.Vti.3FYWJ�\NPKt W/OJJNERS a} UA" E4.r 2.IWW1 L 51W5GN 2.5 NIP.P.ICMIE U.IP5 Af At WA feR Cam n,%5. Z� VER-FY INIERIGR FIN6f,5/Nmr)lNG5 W/GW er-;, �. -' 7:�7^-:Zip-- 4.FO��pJJ VECK CONS(�YCf10N MYfFYJD AS:NCLFl7W/RPNS�AILESS Of1�4Vv1`E AYhE17. ZC��a' 1 / _ ( i.Mll"kRSEVWINVOJJR,'7u";1IA'ErJIN(i5: a. �QN CV 2": Y-51/4"x5'-59/8'. A0o I I I I" 6.vF�ux Si;nlrkrc va.�r�nrrNlr�;S: II I I I I I „I V5 cw:2'.6 I/?"x,,.,, 7-W Q m C} "5 lkray}a co II II: �,�1/V II it I I I r, I I------ Q FOUNPATION PLANFEE: Ci<;�I. EXIST. 'INIJ(,i%gf'hi'N �•.APrI C� � Q �D NEW fv,%; :::: q PECK NOTE5: 1 ^'x— 1 �IEY1' I r-'' I•) CONfPACfOR 15 fO VERIFY EXI5fING CONDI11ON5 AND DIMEN51ON5 '—� is I I 5'JVI?OOM�I I r;;F I y NEbV L—— NE FIEL J 1 :',ri>r•cE: s'.: I———J IN 1 D MOP fO fNE 5fMf OF WORK PECK 2.) COMMAUOP 10 REMOVE EX1511NG 12G'OR5 AND WIN12OW5 A5 SCALE: KOUMP FOR t�W CON5IPI ICfION. / I I HERiEN 1:4'= 1'-0" DATE: I I I EG�NP; 11/7/2000 EX15fING WA11.5 JOB NO.; ,p• " C= C0N5fRUC110N f0 GE REMOVI D MAHER IM NEWCON51PUMN DRAWING NO.: Firl5T FLOOI? PLAN A l TOWN OF,BAARNSTABLE LOCATION 2-3D S�tdl f/ -'1` Yv` ' SEWAGE # VILLAGE Ze 7�a. ASSESSOR'S MAP &/LOT�� INSTALLER'S NAME&PHONE NO. ZiISI��°Cr SEPTIC TANK CAPACITY { / LEACHING FACILITY: (type) �" 1��490'/ � � (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 facili ) Feet X-l®`I Furnished by /��✓� v � �ous� � ' � , o �e Ui No...... Fuic.�..L....................... _.,/ .. THE COMMONWEALTH OF MASSACHUSETTS BOA R9 O H EALT -- --------"--.OF-........ .. - { Appli.ratinn for Disposal Worko Tomitrnrtion Vamit Application is hereby made for a Permit t Construct ( ) or Repair ( ) an Individual Sewage Disposal �Syst at: ; ® ` - - ... -- cation-,Address ddress or I of N _. �e ------------------------------ - .------.. Owner Address W .a ----------------------------------------- ------•-------•-----------•------'•--------------e-s---------5------ � Installer Address Type of Build' / Size Lot.. _.f...�_�f__Sq. feet Dwelling' No. of Bedrooms_________________!.._.........._.....__.._.I✓xpansion Attic (� Garbage Grinder ( ) `-1 Other—Type of Building No. of persons............................ Showers Cafeteria a' Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length__.-___-___•_•_- Width________________ Diameter.......--------- Depth_.-__-___._-.--- x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1......./_.....minutes per inch Depth of Test Pit.................... Depth to ground water__._______-__.--_-__.--- (14 Test Pit No. 2-•-•-.•_--__-__-minutes per inch Depth of Test Pit___________________• Depth to ground water------------------------ = e •-•-----•-• - ---- O Description of Soil....................:. 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 Article XI 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. ��5�7� Signed --- --------•---------------••. ----- ------ ----------------- Date Application Approved By------ _ _ .......... :.. -------•--------- -------------- • Date . Application Disapproved for the following reasons_____________________________________ ---•----------------------------•--------------------- -------------- ---------------------------•------------------------------------•-----------•-------------------------------------------------------------------------------------------------------------------- ---- / Date PermitNo......................................................... Issued-------.....-1 5._ . .....--------- ' Date � No......f -. Fizi@• ::..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6 , OF............. .. Appliration for Bifipoo al Works Tonotrurtioaa Prraaait Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst at Location- ddress or Lot No. ¢# ,g $'/ � ,r�/f/ /Sj/�y .{� �y/p{', �C �y .I ..-_ C. ^' _---.. ...•.d 7'y- G¢..•---•--•..................... ?•.!_®_5`✓�F._Y..'•.. _"!.C::S'J i�^t")••_'f <: - ___ E.! 'bq�G ./.__ Owner Address •.•.......................... .........................................••---•------------ -- aW... --•--•-•-••-•-•--•--•-•---•-----------•----... nstaller Address U Dwell Typeingln No. of Bedrooms________________ ...._____'_._._.._..._..Expansion Attic ( Size Lot•Garbage.41 Sq. feet e Grinder ( ) Other—.Type of Building No. of persons............................ Showers — Cafeteria d Other fixtures ----------------------- - - W Design Flow............................................gallons per person per day. Total daily flow..................,___.___--_-___.______-___gallons. 0.4 Septic Tank—Liquid capacity............gallons Length...............• Width_____________ Diameter......---------- Depth__--_____-___.- 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 ( ) a Percolation Test Results Performed by............................................................... ........... Date----------------- -----------::......- Test Pit No. 1-____---/._...minutes per inch Depth of Test Pit-------------------- Depth to ground water________________________ r14 Test Pit No. 2...........:....minutes per inch Depth of Test Pit-_-_-____----_______ Depth to ground water_____________________-_- O f -----.................. Description of Soil ....... <- r��:.., :- E f �-^f. �!•.......---- c , x UW ----------------------------------------------------•-----------------......•.....•--•••--•---"--••-•••-----------------•----------...-••'••--•-•••-••--•-----------............--------_----- 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 Article XI 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. r• Signed _. ;. '' �: -------------------------- A Application Approved B ......... � t Date PPPP Y - - -----.... ------------------- ------------------ Date Application Disapproved for the following reasons:..........................-------•-•••-•••----••--•--••-•-------------------------••......--•-•----------.... s Date Permit No......................................................... Issued...------=`1=`� ,-----.ems.-.a,.............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .......O F.:... ... .. . ................ to ... �'`° �....... d`� may.< • • C-En ifira#r of ToutpliFatta THI IS TO CERTIFY, at the Individual Sewage Disposal System constructed (V) or Repaired ( ) bY---.,----- ...................................-••'•-- --- --•- --- ----••... ---- -•--••......-- ...... i f staller atA `t .... (Ja.. `- .• _:._ ,p-_m-_ _,�`f✓'v vi_41':.__4X�"e.-<Fg,,:C/�s°"_.� 1 4 y has been installed in accordance with the-provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....................f�'e...Ir......... dated_--:,T_-._:__,�----zr_........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU CTION SATISFACTORY. ----- --= ?'j DATE �� p1_.� Inspector ".�' ---' ' '; 7 THE COMMONWEALTH OF MASSACHUSETTS I BOARD OF HEALTH .............. '' No.... ................. FEE.12 • --•--••---- �t��o� l ork� C�ora�# r#io$a �rraati# Permission is hereby.granted------. --- - ---------...•..... to Construct ( -or•Re, air ) j Indivi al See tspoal System Street as shown'on the application for Disposal Works Construction Permit No Dated____-- :,/�.:�/ ....... r ry d ' / i %� Boarcf"if mealtl ff DATE.- •ur :�►~ ��-' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS N0f _ !.! FEz. .......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Dhrip ial Work,i Tomitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: , /1 /....._....s.�_:.�o-°-'--------S--fi.................. ........(�...`.' :c._..... Location- d s or Lot No. O.vye Addres Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) p" Other fixtures _______________________________ _ _ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width________________ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.....................Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) .-t Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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........................ Ra' --------------••--------.._..---•-------••------••-•-----------------••----•---•---•-•-......_.....•......................................................... 0 Description of Soil...................................................................................-.................................................................................... V ....................................................._...•-•--•----•--••----••---•----•---•---•----------••--------••-•---•-------------•-------••-------•--••-•-----•--•-•--•--••-••----•--•----....... -------------------------- ---------- ---------------------------------------------------------------------------------------- V Nature of Repairs or0-1 e ns=Answer when applicable._._._.___( __ __.:_._....._......__._........... -----------------•-•---------••-- 07 O� ° -------------------------------------•---------•-----------............---•- Agre went: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli s iss a by t board of heaa h. Signeds/ / r---�� . ............... .................Dace.....----------'- Application Approved By ............ .�..Aec �`.,,-.,,y- ---------------------------------------------------------------------._. ......../L Dace Application Disapproved for the following reasons: ............ ..... ....... .._......... ........... ......_................._.... ..... ............................................................................................................. .....--------...........---- -..............------........-------------------- ........................................ Date Permit No. .....�. A - ............ � Issued .. ?..... . ........_..... ................................ Dace i ad ( 00 FRs ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appfiratiun for UinVuual Work.6 Tomitritr#inn i1Pruti# Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at:/ t ` � �^Location-l�dd jgsr or lot No. �J lam^' .�.,.�-�-^-• ..........-•-----_____.......................................•---............................... -••-•----•--•-•...••-•••••---------•-•.....-•---••••--••-•.....•-•_............................... Ow er Addres P ` --------------------------------------- �7`-- ... l - o Installer Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) p,, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width-.-..-.-.-.----. Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.-.-..-.------.----- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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........................ F - ,�-• -- -• --•s 0 Description of Soil..` .---••---•-••------•••••••••••-•-••-•-----......•----...---•---•--------------------------------•-•--•••••----•----•----••--•-----------•---•••......-•---•- x V ...--•-•-....----•-•-••-------•-•-•-•--•••••---•-•----•••-------•------••---••--•-••----------------••-•-••-•-------------•••-•---•-•---•----•-•-•-••-••-•---•-•-•••-•--..............---•-••-•--------- x ••••-•••--•-------------------------------------••-----.-----....---•.--.---.---..--.•-----......--•------•--•--------...-!..------ --�.-�--- U Nature f Repairs or lte-ations—Answer when applicable.--------1. .�. ------ -- .•••-- ;�C� ,. �� x....................................................... --------------•------- --------------------------------------.......--•-•---- Agreement-. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ycr. Eon issue by t board of hea th. Signed £--- .. - -----�% � \ 1- Dare Application Approved By ................ .. .--^ - -... 61' Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------------------- v. .. ............................. .......... ... ............ . ---------------------------------------------------- ---------------------- Q �t, Dare Permit No. ! --- ---------------------- Issued .. -- ........................ ........ . -- Due ------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE • C�elr#tftrate of Complia ue THII S TO CERTIFY, hat he Individual Sewage Disposal System constructed ( ) or Repaired by.......� �--� �-�-----..�. --r-�-.---1..... .... - .... - ----- ---------- --------- at .. .'-------------�--- `'1.a C l Q U t has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. .._... y.-.....(.. l6.- _- dated ........._........_----_....--......_--- ... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM W LL FUNCTION SAT'ISFACTORY. �� DATE.- ,/... - / - Inspector ... j .. - 2 l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q / TOWN OF BARNSTABLE GI....G/... FEE`a .-. No..... . �iuNNnu�t nr�$ nu ttr�inn �C.ermi� ` Permission is hereby 1---..�- f 5-------------------------•---------------•-----------••-------......... to Construct ( �) or Repair ( (� an.Indio`dual Sewage I�' posal System �" � '�t✓I / /'��(�?�%�� J �,,,,�� L/ V f �/f Street � ��j -� l as shown on the application for Disposal Works Construction Permit No. y'r/_�--1�.4ated...._ .`.f.;/...�. 1 ._.. / . 1_...>. --------------------------------------- ' Board of Health t _ DATE............;��' I J = �--•-------------------- -------- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS 20'-O" AXI51", 5'-6" A5 2'-10" 2 -10" 11 6'-10 2'-0" 1 5UNf?OOMI 10 PACK 1 nN, .• A A A Exlst. 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MAHOGANY P.T. x - 2 8 - 5 1/4 _ l 0 - I CAAP\AG� L •- i f, 1 - : �16 o,c , f -. .NEW 9 t 2 TRU55 J I T@ I 5/8 FIR)COI?E GYP,W. ff ! os s 6 0�. , 2 P.T.2 x Os ' ON SLAB - 3 L ON I x STRAPPING DATE : SLOPE 2 T .. " OJJARl75 C l6 o.c. _ I _ nooR> 4/12/2 003 . NSW p W AC 2 coNc.�,Ar SIC I I AI. G .AGE N . PROP TOP F JOB O . I I, 0 FOUNp, I W AT O.H.p0iC)R5` I ALI. MAHE .. R I I C r oNs , 41 oNc ff • :: ' � PT t NSW O CN 2 0 ON.DOORS plAw 50N0i1.�5 DRAWING NO. f04- f _ r�L owGr�ApE ulr I F N C N _ _ _ NFW MU n o0 M r . . APRON DUI APING 5�CfION N f f . o c �W GApJ�G� f z_ ff 9 8 6 i9 O , .. - ..... �..... -.;� -.�..�._,. .gin ... v: