HomeMy WebLinkAbout0006 SCHOOL STREET - Health r
{ 6 School Streetrt
035-054 Cotuit
TOWN OF BARNSTABLE LOCATION COS eikWl STr-ee,r SEWAGE#_3^5P
VILLAGE 0'cqU 1 t- �ASSSESSOR'S MAP&PARCEL
� S NAME&PHONE
�N�O_. �')c riLlC
SEPTIC TANK CAPACITY asSPW
LEACHING FACILITY.(type) OVkt-g Wc-0 ��� (size) (60G
NO.OF BEDROOMS
OWNER Z-06,►POd W'Tru
PERMIT DATE: C%9444)�WE DATE 1
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
P a7cool. ree.a h S l
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39 `'
-Carauel
driv..eway ;.
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10 ;!
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LO CATION S EW A G-E PE RMIT NO.
G C)OL - -STRE jE7 5 a&-
VILLAGE
COTVlT� -M
INSTALLER'S NAME & , ADDRESS
.=l vtvlE� T AO psz"►\Il �7-79-0
��5
d UILDER OR OWNER
DATE PERMIT ISSUED - gS
DATE COMPLIANCE ISSUED
1
`DW�LLItJ(o ..
to
10` Z�
P
m ,
t
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
ApplirFatinn for Uiipusal Works Tonstrnrtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................ ........................... .�'-�? t....�. .................................................
s� ocation`-Address or(�t No.
............... ....... ......................--.....
Own r Address
a .................. .��--d ,c° ------------------------------------- ------, -* -- °ti,tii �� non, - ...........................
Installer Address
� Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
U
Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixtures -----•--------------------------------------------•-----------------•----•----------------------••-•------•-•-•--------••------•-•-•.........-•------
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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 •---•---•--------------------------------•------••-------•-•-•--•--•........._...................---.........................................................
0 Description of Soil........................................................................................................................................................................
W t! r3 VV r-
--------------- --------------------------------------------------------------------------------------------------------------------------------------•---------------------•--.._.....-----••----••-•--
UNature of Repairs orAlterations—Answer when applicable..___.J_ ..__._q.i"T......S off®.------ _`..................^_....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'i i� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has sued by th board
Sied.......... ........• ...... .........................................-•.. ........... ---�--
Date
Application Approved By--••---•--•---•-.• ..-- --- • . .... ............... ............. ZV
Date
Application Disapproved for the follo ing reasons:.......................................................................................I....................._
---------•----•----------•-------•----------•-----------------------•---•----•------------............------•--•-•--••-••-------•--------------•------•----•--------•--••-----•--------------•••••••--
Date
PermitNo......................................................... � Date Issued-----..........•--- ----------•--....... ..._..
No......................... Fizz..........................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L_V%re-...........-OF. .e.....w a GA j ... '
ApplirFa#iou for Disposal Works C>ruatstrurtiuu Fumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�'
... - ------ ..-.
c... .... ..------•------•....................................•
Location
`-Address ov-Lot No.i*`-
--.... ..�.:r. --------•---. •-•--- --------------------• -•--........ -..........------......._.....
W
n Address
........Lv '
Installer Address
g Size Lot.................... .
U Type o Buildin .......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building a Other—Type g ____________________________ 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 ( )
aPercolation Test Results Performed by................................ Date........................................
Test Pit No. I...........:....minutes per inch Depth of Test Pit._................._ Depth to ground water........................
Pro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 .---•-----------------------------------•---------••--•--•----.......-----.....----............................------...........----•--•••••---••-•----•--_..
0 Description of Soil........................................................................................................................................................................
V ..............•-•-•----.......••---•--•-•••--------••.......---...•---------•....•••-------•--------•-••••------------------•------•----••------••-....................................................
.................................................----------------------------------------------•-••-------•-----•-•...._L!._l.._.. A v�c............--- ..._... •-••------------
>.V Nature of Repairs or Alterations—Answer when applicable._--___I_C Q.....
.____. :e ------r .t___.........................
--------------------------------•--•-------•--......._...--------------........------••-•----•----............---------------------------------------------------------------•••-•---•--•...._..--.-•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has n iss� �u�ed_by the board health.
pS1ed.. __ ...I .............�'------•.-----•--- --•-----•--- •�---_-- --------------Date
Application Approved By---••--•-- -•-----_V 6/ - . --- •'-• ---------. DateApplication Disapproved for the folloreasons:.............................................-•-----------------------------------------------------------•---
--------•.......••••---••-----•-•----••---•-•---••••-••-•-----•••••••-•--...-••--••------•••••------••••.--........•--•-•-•••-•-----------------•-•----------•-----------•---•------•••••-----••••----•.
Date
PermitNo........................................................ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... a......OF..........` .............................
Trrtifiratp of Tnutpliaurr
THIS IS TO CERTIFY, That the Individual Sew isposal System constructed ( ) or Repaired ( )
by------------------------------------------- ? r - u - \ 'tea �.- ---------......-•-----•-•--.......•.....................-•-----•---
�'1 Installer
avc;N - ,
has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No............................. .......... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUED AS A GU717
THE
SYSTEM WILL FUN TIO SATISFACTORY.
DATE....................•�..Uj..65..................--. ..... Inspector. ....
THE COMMONWEALTH OF MASSA SETTS
BOARD OF HEALTH ( ,
..........................OF.....................................................................................
FEE........................
1, f Disposal Vorks (tuuu#r irru rrutit
Permission is hereby granted.----------- •-----•••. •-------------------------------------------•••-•..._-•--•._........
to Construct ( ) or Repair ) an In vid ewage Disposal System
atNo......................... . ... •-----._.....
Street r
as shown on the+application for Disposal Works Construction Permit No� Dated..........................................
._ -------------
-------------------------
--
DATE.`____.7�.. -�. •� - oa a h
FORM 1255 A. . SULKIN, NC., BOSTON
i
' commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 School Street
Property Address
Longfield Realty Trust
Owner Owner's Name
information is required for Cotuit MA 02635 May 28, 2008
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Impotent: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
. .Company Name
189 CammettRoad a
Company Address `
Marstons Mills MA 02648
Cityrrown State Zip Code
508-428-1779 SI 12855
Telephone Number .' License Number
B. Certification §-
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. lam a DEP approved system.inspector pursuant to Section-15.340 of
Title 5(310 CMR 15.000).-The system:
® Passes s- ❑ Conditionally Passes ❑ Fails
❑ Needs'Further Evaluation by the Local Approving Authority
e� V0May 28,2008
Inspector's Signatur Date .
The system inspector shall submit a copy'of this inspection report to the'ApprovingAuthorit (Board
of Health or DEP)within 30 days of completing this inspection. If:the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
,report to,the appropriate regional office of the DEP: The original should be sent to the system owner
and,copies sent to the buyer,.if applicable, and the approving authority. .
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
08-131 Longfield RT.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
6 School Street
Property Address
,
Longfield.Realty Trust
Owner Owner's Name
information is Y required for Cotuit MA 02635 May 28, 2008
every page. Cityffown State Zip Code Date of Inspection
B. Certification*(cost.)
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:
Cesspool was pumped as part of inspection, overflow pit had never been more than 1/3 full.
B) System Conditionally Passes:
p One or more system components a 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, notleaking 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
08-131 Longrield RT.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 o1 15
Commonwealth of Massachusetts
Titl
e 5 Official _ _
e al Inspection- Form
Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
6 School Street
Property Address
Longfield"Realty Trust
Owner Owners Name
information is
required for Cotuit
4 MA- 02635 , May 28;2008
every page. Cityfrown State Zip Code Date of Inspection
41
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ t 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 fis removed
-ND Explain:
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
1.5.303(1)(6)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 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 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.
08-131 Longfield RT.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts- ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 School Street - m
Property Address.
Longfield Realty Trust
Owner Owner's Name
information is Ctuit r MA 02635 May 28, 2008
o
required for y
every page. CitylTown State Zip Code Date of Inspection
B. Certification
C) Further Evaluation is Required by the Board of Health (cont..):
❑ 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`DERcertified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be-
attached to this form.
3. Other:1.1
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup:of sewage into facility or system component due to overloaded or
clogged SAS or cesspool ,
❑ ® :Discharge or,ponding of effluent to the surface of the ground or surface waters
.due town overloaded or clogged SAS or cesspool
® Static liquid level in the distribution box above outlet invertdue 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. .
08-131 Longfield RT.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts .x
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System'Form Not for Voluntary Assessments
6 School Street
Property Address
Longfield Realty Trust - "
Owner Owner's Name
information is Cotuit MA 02635 May 28; 2008
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
i
D) System Failure-Criteria Applicable to All Systems (cont):
Yes No
f ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
® Any portion of a cesspool.or privy is within.50 feet of a:private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform'bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd
0 ® 10,000gpd.
The system fails. I have determined that one or'more of the above failure
❑ ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.'
E) Large Systems: To be considered a large system the system must serve a facility with.a
design flow of 10,600 gpd to 15,000 gpd..
xFor large systems, you must indicate either yes or"no"to each of the following,in addition to the
questions in Section D.
Yes_ No
❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
EJ El Area—.,IWPA)or a mapped Zone LI of,a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes"°in Section D above the large system has failed: The owner or operator of any large
system considered a significant threat under Section,E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
08-131 Longrield RT.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts . :
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
6 School Street
Property Address M
Longfield'Realty Trust
Owner Owner's Name
information is. Cotuit MA 02635 May 28, 2008
required for
every page. Cityrrown - State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes .- No
❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two'weeks?�
® ❑ Has the system received normal flows in the,previous two week period?
e ® Have large volumes of water-been introduced to the system recently or as part of
this inspection? ,
Were as built plans of thesystem obtained and examined? (if they were not
® available note as N/A)
f I
® ❑ Was the facility or dwelling inspected for signs-of sewage back up?
1Z ❑ 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?,
® " El information
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 Soi[Absorption System (SAS)on the site has
been'determined based on: `
Z ❑ Existing information. For example, a plan at the Board of.Health.
® a 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)]
15
08-131 Longfield RT.doc-08/06 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 School Street
Property Address
Longfield Realty Trust
Owner Owner's Name -
information is wired for required .Cotuit MA 02635- May 28, 2008
_
every page. CitylTown State 'Zip Code Date of Inspection -
a
D. System,Information
Residential Flow Conditions:
Number of bedrooms'(design): Number of bedrooms (actual):..
DESIGN flow based on 310 CMR 15.203 (for example. 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder? ❑ Yes. ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes ,❑ No
Laundry system inspected? - El Yes'[- No
Seasonal=use? ❑ Yes ❑ No y
Water meter readings, if available(last 2 years usage(gpd)): .
Sump pump? ❑ Yes Q No_`
Last date of occupancy; - Date
Comm ercial/Industrial'Flow Conditions: F
Type of Establishment.; Office Space
75 gpd/1000 sqft or 200 gpd min. '
Design flow(based on.310 CMR 15.203): Gallons per day(gpd)1.
a
Basis of design flow(seats/persons/sq.ft., etc.): 1254 sgft= 94.05 gpd (200 gpd Min.)
Grease trap present? ❑ Yes ® No
Industrial waste.holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
r r -2 yrs. 27,000 gal. =40 gpd.
Water meter readings, if available: .
Currently Occupied
Last date of occupancy/use: ' pate '
Other(describe):` G m
08-131 Longrield RT.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y 6 School Street
Property Address
Longfield Realty Trust
Owner Owner's Name
information is Cotuit MA .' 02635 Ma 28 2008
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cons.) =
General Information
Pumping Records: -
Source of information: None
Was system pumped as part of the inspection? ® Yes El No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined?
Reason for pumping:
inspection. .
Type of System:
El 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)
In 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:
Overflow pit installed 7/31/85
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-131 Longrield RT.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 School Street
Property Address
Longfield Realty Trust
Owner Owner's Name
information is required for Cotuit _ MA 02635, May 28, 2008
every page. Cityfrown State Zip Code Date of Inspection
D. System. Information (cont.)
Building Sewer(locate on site plan):-
6, ,
Depth below grade: feet
Material of construction:
® cast iron ❑ 40•PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete T❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
08-131 Longrield RT.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 .
Commonwealth of Massachusetts
Title 5 Official Inspection . Form t
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
6 School Street
Property Address
Longfield Realty Trust -
Owner Owner's Name }
information is y required for Cotuit "MA 02635 May 28, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) `
Comments (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, .
liquid levels as related to outlet invert;evidence of leakage, etc.):'
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.):.
Tight or Holding Tank(tank must be.pumped at time of inspection) (locate on site plan):
Depth below grade:
44; -
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
I
08-131 Longfield RT.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts,
Title 5 Official Inspectionfd M
Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments
6 School Street
Property.Address
Longfield.Realty Trust
Owner Owner's Name
information is -
required for Cotuit MA, 02635 May 28, 2008
every page. Cityfrown State Zip Code Date of Inspection
D. System Information'(cont.)
Tight or Holding Tank(cont)�
Dimensions:,,
Capacity: ,
gallons'
Design Flow: gallons per day .
Alarm present: ❑' Yes TT No
Alarm level Alarm in working order: ` ❑'Yes ❑ No
Date of last pumping: pate
Comments(condition of alarm and float switches;etc.): „
*Attach copy,of current pumping contract(required). Is copy attached? • ❑ Yes'• ❑ No
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.):
Pump Cfiamber(locate on site plan): f
Pumps in working.order: ❑ Yes ❑ No
Alarms in working-order: ❑ Yes ❑ No
08-131 Longrield RT.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official InspectIon form t
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
6 School Street
Property Address
Longfield Realty Trust
Owner Owner's Name "
information is required for Cotuit MA. 02635 May.28, 2008
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont)
Comments(note condition of pump chamber, condition of pumps and appurtenances,.etc.):
' Soil Absorption System (SAS)
.(locate on site
pIan �excavation�not required):ed):
If SAS not located,explain why:.'
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching.fields number, dimensions:
One 6x6 precast
® overflow cesspool number: pit.
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.): "
Overflow pit had one foot of standing water with a high stain line one foot above current level leaving
four feet of effective leaching.
k
08-131 Longfield RT.doc•0a106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 o115-
Commonwealth of Massachusetts -
Title 5 Official Inspection -.Form t
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
6 School Street
Property Address r
Longfield Realty Trust
Owner Owner's Name y
information is required for re4 Cotuit '' MA " 02635'' = May 28, 2008
-
every page. City/town State Zip Code Date of Inspection
D. System Information (C'ont.) A
Cesspools(cesspool must be'pumped as part of inspection) (locate'on site plan):
• Number and configuration One with overflow pit. ;
Depth-'top invert
•2
of li uidto inlet
,
1.
Depth of solids layer 0
t.
6;,
Depth of scum layer "
6x6
Dimensions of cesspoolw`
Materials of construction Block
Indication of groundwater inflow El Yes ® No
Comments (note.condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ;
Blocks are structurally sound, cesspool was pumped as part of inspection. Recommend pumping,,
annually. .
Privy (locate on site plan):
Materials of construction:
` . Dimensions ,
IA
Depth of solids
Comments,(note condition of soil,'signs of hydraulic failure, level of ponding, condition of vegetation,
- etc.):
08-131 Longrield RT.doe-08108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
,per
.\
Commonwealth of Massachusetts' `. - s
Title 5 Official InspectionvForm
Subsurface Sewage Disposal System Form Not for Voluntary�Assessments
6 School'Street ,
Property Address '
Longfield Realty Trust,.
Owner. Owner's Name - �• "
information is Cotuit _:; MA" — 02635. May 28,2008
required for ;State ` Zip Code Date of Inspection
every page. City/Town
D. System Information (cont )
Sketch Of.Sewage Disposal System:11 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. '. s
School Street."
w.
♦ \ \ \., \ , ♦ \ \ \ \ ,
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\','\'\'\'\'\'\'\' LJU _
/ / / J / / / / / m
-
/ ......... xavW
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, , ,:, , , \ \ \ \ \ \ , `10
Commonwealth of Massachusetts -
Title 5 Official Inspection-
Form
Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments
6 School Street
Property Address
Longfield Realty Trust
Owner Owner's Name
information is required for Cotuit MA ,_ 02635 Way 28, 2008
��,
every page. Cityfrown Y State Zip Code Date of Inspection
D. System Information (cont)
Site Exam:
® Check Slope
Surface water s
Check"cellar
® Shallow wells =
Estimated depth to ground water: e0t
n water elevation:Please indicate all methods used to determine the high ground a
9 9 �
❑ 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)
T ® Accessed USGS database-explain:
USG$topo map and town GIST
You must describe,how you established the high ground water elevation:
Town groundwater.,contour map shows water below el.5 and topo map shows property above el. 30.
08_131 Longrield RT.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
f
Town of Barnstable
Cf ZHE)�
Regulatory Services
e BARNSTABLE, * Thomas F. Geiler;Director
MASS.
9q, 1639. ,0� Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
r
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this.Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC
July 19, 1985
bir. Rodger E. Roberts
23 Jennie's Path
Hyannis, t.;A. 02601
Re: Variance for Bruce Burlingame - corner of School & Aiain
Streets,Cotuit
Dear Mr. Roberts:
You are granted a variance on behalf of Bruce Burlingame to install
a septic leaching pit six feet from existing buildings at property located
at School and Main Streets, Cotuit, with the following conditions:
The pit must be constructed to withstand H-20 wheel loads.
This variance is granted because the existing cesspool has failed. 'There
is no other location on the lot suitable.
Very truly yours,
obert ilds ~
Chairman
BOARD OF 1- EALTH
TOWN OF BARNSTABLE
JMK/ram `
f n' No.
DATE
y f T M�rO 3�
TOWN OF BARNSTABLE FEE
OFFICE OF
DAHI7
IIAaL ' BOARD OF HEALTH
-• "
i639' 367 MAIN STREET
QED Y11Y k'
HYANNIS, MASS. 02601
VARIANCE REQUEST FORM
All variance requests must be submitted five (5) days prior to the scheduled Board of
Health meeting.
NAME OF APPLICANT o���;-e�' =- `� a L� e� S
ADDRESS OF APPLICANT �3 J�vv t'�•`c e S �'�~��'�►
NAME OF OWNER OF PROPERTY r
SUBDIVISION NAME DATE APPROVED
LOCATION .OF REQUEST - - C'�Y N e.2 f- S c.�.�o� -i- `N��\i,. S^ G O �~ `A 1•. C``/ -.:--
VARIANCE FROM REGULATION (List regulation) W'ti- -\.� `� m Fe ��5' ► S -
VARIANCE- REQUESTED (Specific request) -ea ,y . eidh �;�cl�:Lc� ;;v`.'� <:DY\J--e
L(gVV ' r�rp \\o v �� act ��q�`. p;� Vj-Z
REASON FOR VARIANCE (May attach letter if more space needed)
PLANS -'Two copies of plan must be submitted -clearly outlining variance requested.
VARIANCE APPROVED
NOT APPROVED
REASON�FOR DISAPPROVAL
Robert L.. Childs,. Chairman
Ann Jane_ Eshbaugh _
Grover C.M.. Farrish, M. D.
BOARD OF HEALTH
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