HomeMy WebLinkAbout0071 SCHOOL STREET - Health 71 SCHOOL
TOWN OF BARNSTABLE
LOCATION SEWAGE# Jq7
VILLAGE C04i;\k ASSESSOR'S MAP &LOTQ3 ^a/X
INSTALLER'S NAME&PHONE NO. `5 C_O�S rl
SEPTIC TANK CAPACITY k S-06 G4 — d
LEACHING FACILITY: (type) �42 ,r,,,,-\A S'.5 j(size) LA V+:5 ..?. fr XSn�
NO.OF BEDROOMS
BUILDER OR OWNER GrQ -won . 1 -
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the: 1
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7 °�a Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) AA9, Feet
Edge of Wetland and Leaching Facility(If any wetlands exist MI-A, Feet
within 300 fee f leaching facili
Furnished by
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No. ` 1✓ Fee 00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes �+
Tipplitation for Misposal *pBtrm Construttlon 3permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 70 Owner's Name,Address,and Tel.No. aS
Assessor's Map/Parcel 3 S 2Z v\V
Installer's Name,Address,and Tel.No. 5C c3yv Ircq_x Designer's Name,Address,anA Tel.No.
6A Gs
Type of Building:
Dwelling No.of Bedrooms OL1 I4— Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided�',,Z gpd
Plan Date Number of sheets Revisibn Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by F ZC Date
Application Disapproved by Date
for the following reasons
Permit No. �� 3 Date Issued /
�'•�''s:3 r:.• �-.^•:.x,rf _��.$,,.-�:.,'r-.�"t {�; _ `: _ _ ¢ `.�"''wY-,r�.T„!`..._.� ��
r.. �v,
r
• - is., -r ,a,. ii' . .
No. Fee
THE COMMONWEALTH OF MASS'ACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTAB,LE, MASSACHUSETTS
M-1
fiprication.for Misposal *pstem Constru"lion Permit a
r/ - +
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) Complete System ®individual Components
Location Address or Lot No. -70 Owner's TName,Address,and Tel.No. �'�e� Scu'1
Assessor'sMap/Parcel S 2-7- ` :. v\ _ _ 1-nmo_ Lo
Installer's Name,Address,and Tel.No. ,�, r Designer's Name,Address,and Tel.No.� _ --
i ► �tvsrn C
Type of Building: , --
Dwelling No.of Bedrooms v - Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) WIN N gpd Design flow provided �9 gpd
tea.; Plan •Date Number of sheets Revision Date
rr Title
Size of Septic Tank Type of S.A.S.
Description of Soil E
Nature of Repairs or Alterations Answer when applicable) ,-N
Date last'inspected: 3'y'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed n t �, ` Date-. /
Application Approved by �\ Date . / a
Application Disapproved by Date '
for the following reasons
Permit No. O. J Date Issued / �'b /
Wy
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
d,6x Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�)� Upgraded
Abandoned( )by S� ,,)r� �• �nr�y- • n!.
r �
at i has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.')U,a r,a(/''(" dated
Installer Designer#bedrooms �� Approved design flow A)tt gpd
The issuance of this Oermit hall not be construed as a guarantee that the system will n ions design
Date J d ( Inspector fa tfL_�.� j
}< <, No. 117 D Y ' Fee " 7 fir'-,
THE COMMONWEALTH OF MASSACHUSETTS
caPUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
1
Misposal 6pstem Construction Permit
'Permission is hereby granted to Construct( ) Repair(o' Upgrade( ) Abandon( )
System located at e rN,nc2A `G44 , C pm ;
`f. n and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her.duty to comply with
t p Title 5 and,the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date'of this permit.
Date
f!1 Approved by r ..✓,�..LP 1 '�:'., . .
. rt
Barnstable
Try ray,
Town of Barnstable MMMMUM
fn.Msr".E
A " Regulatory Services 'Departmen't
rfa � 2007
- Public Health Division
200 Main Street, Hyannis MA 02601
OFFICE: 508-8624644 Wayne Miller,M.D.
FAX: 508-790-6304 Junichi Sawayanagi
„'. Paul Canniff,D.M.D.
September 25,.2014
Re: 71 School Street, Cotuit, MA
To Whom It May Concern,
Town of Barnstable Health Division records indicate that the.Sewage Disposal System
located at 71 School Street, Cotuit MA was constructed in accordance with the provisions
of Title 5 on April 24, 1996.
Sincerely,
s McKean, R.S. CHO
y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
In
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer, U
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin
use the return Name of Inspector.
key. ,
Neighborhood Waste Water
Company Name
350 Main St
Company Address
W.Yarmouth MA 02673
Cityrrown State Zip Code
508-775-2820 S15016
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems.1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
c ' ® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
C) F- i
c�w _ 10/6/2014
Lt �—��-� Date
Inspectc�s S g
d C i �-•
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 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.
ed
10 �o l
t5ins•3113 Title 5 Offldal Inspedio, F ubsurface Sewage D sposal System•Page 1 of 17
' ) r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System in good working condition.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
,M 71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Cityfrown State .Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval,of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping.more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Cityrrown State, Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**. r
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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El
® Backup of sewage into facility or.system component due to overloaded or
clogged SAS or cesspool
11
® 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 '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
El ® tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ 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
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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® '❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): N/A Number of bedrooms (actual)` 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): N/A
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last'2 ears usage d 2012=148gpd
9 ( Y 9 (gP )) 2013=162gpd
Detail:
r •
Sump pump? ❑ Yes ® No
Last date of occupancy:. Current
Date
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:'
Source of information: No Records
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? - -
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool .
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy,of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
18 Years per Compliance.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1'10"
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
+10'
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.).
Line inspected with sewer camera and was found to be clean, Properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1500 Gal H-10
Dimensions:
Sludge depth:
7"
t5ins°3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 30"
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle . 5
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Sludge Judge/.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.):
1500 Gal H-10 tank in good condition. PVC tees in place and clean.Tank at normal operating level.
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth f a o Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02636 10/2/2014
page. CitylTown State Zip Code bate of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level Alarm in working order: ❑ .Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
01
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.):
H-10 DB-3 with 1 dine in and 1 line out in good condition. Box is clean and level with minimal signs of
solids carryover. No signs of overloading or hydraulic failure.
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.):
a :
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts -
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635' 10/2/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers , number: 4-Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ Teaching 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.):
4-Infiltrators with 4'of stone all around. Leaching in good condition with 1"of standing liquid in units.
No signs of overloading or hydraulic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Numberand configuration
Depth—top of liquid to inlet invert
Depth of solids layer
z.
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below.
❑ hand-sketch in the area below
® drawing attached separately
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t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is required for every Cotuit MA 02635 10/2/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 2 fe eett
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:
Hand auger near leaching to T with no groundwater encountered..Bottom of leaching at 24".
Minimum of 4'8"observed separation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
:
Commonwealth of Massachusetts
Title . Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . .
71 School St.
Property Address
Gordon Hill
Owner Owner's Name
information is .}
required for every Cotuit 'MA. 02635 10/2/2014
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D,4
or E checked
® Inspection Summary D(System Failure Criteria Applicable to AllSystems)completed
® System Information—Estimated depth to high groundwater is
® Sketch of Sewage Disposal System 6either drawn on page.,15 or attached in separate file
t
.. a:
_ 0 "
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System♦Page 17 of 17
Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE
LOCATION` I SG1nt�D1.� MVAGE ti (ily 7
VILLAGE Coft nk ASSESSOt'S MAP&WT4 -4/6
t.
INSTALLER'S NAME&PHONE No. S c'0�t ('1 CczanV_
SEPTIC TANK CAPACITY S-06 G-kL 0 (3isX
LEACHING FACUM:(type) I_tz(,Q_\Ac"rs •(sin) LA T':5b',P M.Mci
NO.OFBEDROOMS 3 I��C v.-J /
BUILDEROROWNER 'cr&00r\ Nn11 -
PERM]TDATE: COMPUANCE DATE: �6
'Separation Distance Between the: ' A
Maximam Adjusted Groundwater Table and Both of Leaching Facility' 4 J Feet
Private Water Supply Well and Leaching Facility(If any wells exist ,
on site or within 200 feet of leaching facility) AR— Feet
Edge'of wetland and Leaching Facility(If any wetlands exist r L'
within Mf f leaching
Furnished by +,
H V
A 4o
B_6 1 F}
13+0
(3aCc1
Cltw�UJ�
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http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=035016&seq=1 10/1/2014
96
_10?
No. Fee
—2e
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppricatiou for ]Digpoga1 *pgtem Cougtruction permit
Application is hereby made for a Permit to Construct( )or Repair( t/jan On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Installer's Name,Address,and Tel.No. C t Designer's Name,Address and Tel.No.
Type of Building: V
Dwelling No.of Bedrooms�P� Garbage Grinder J)a
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) X.5n Q Crza L l C -' C) FJ x
l W q '( &,r-QUAJ t LL' �.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is d by this Board o C
Signed Date �'/
Application Approved by a
Application Disapproved for the following reason
Permit No. Date Issued
n77"
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN'OF BARNSTABLE., MASSACHUSETTS
01ppYication for Miquaf *pgtem Construction Permit
Application is hereby made for a P&mit to Construct( )or Repair( 1/fan On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Installer's Name,Address,and Tel.No. C �^ Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /SZ)y Greek(. �l ��C �GtJa.�� `1J Qy)C
C-4--OU J f LI` nCJJk S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is d by this Board o .
Signed Date
Application Approved by
Application Disapproved for the following reason
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or re2aired/replaced(L./)on
by SC-6V\ !, R- &kZ for Cr6r3n, \Ak k)
a* -7 1 Sc. \,xc, has P.Qqconstructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Use of this,system'i conditioned,on compliance with the provisions set fo _bel w:''� "' .f
s
_ ---------- ----------
No
/ j �M ' Fee r
THE COMMONWEALTH OF MASSACHUSETTS Y
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Di.5po!5a[ *pztem Construction Permit
Permission is hereby granted to
to construct( )repair( 6-f an On-site Sewage System located at �G6�.ter f -Q-{ Cc�- ►�-�
and as described in the above Application for Disposal System Construction Permit. The applicant recogni es his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be c /lete ith; Approved
' o years of the date below. ;
Date: / by ���
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, �� M ��e � , hereby certify that the application for disposal works
construction permit signed by me dated / 10 f rf fo , concerning the
property located at t nrz S14 Cadv1zk meets all of the
following criteria:
t i
A�There are no wetlands within 300 feet of the proposed septic system
here are no private wells within 150 feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
/Mere is no increase in flow and/or change in use proposed
(• There are no variances requested or needed. i
SIGNED: DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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