HomeMy WebLinkAbout0251 SCHOOL STREET - Health 251 School Street - -
Cotuit
A= 020-100
I�,
Commonwealth of Massachusetts 00?0—/0 0
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `x
251 School Street
Property Address �
Caroline Tarolli R
Owner Owner's N a a
information is Cotuit ►� Ma. 02635 07/13/2017 �
required for every .
page. City/Town State Zip Code Date of Inspection
' ��•i
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 ,c y
filling out forms v/� /
on the computer, I a 1
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
use the return Name of Inspector
key. -
Cape Septic Inspections
ITV Company Name
624 Old Barnstable Road
Company Address
I Mashpee Ma. 02649
City/Town State Zip Code
508-280-3356 Si3938
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. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
07/14/2017
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface S.g!Isposal System•Page 1 of 17
Commonwealth of Massachusetts
L Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ti
251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
page. City/Town 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:
This 3 bedroom home has has a four bedroom septic system it has a H-10 1500 gallon septic tank
and a H-10 D-Box feeding three leaching chambers. At the time of the inspection there were no
visible signs of past hydraulic failure.
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 oldis available.
❑ .Y ❑ N ❑, ND (Explain below):
a e
r
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
page. City/Town 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.doc-rev.6/16 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
°M 251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
page. City/Town 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".
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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
❑ ® or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins.doc-rev.6/16 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
°�M ,•'°p 251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
page. Citylrown 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
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.
❑ Z. 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.doc-rev.6/16 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
M 251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
page. CitylTown State Zip Code Date of Inspection
C. Checklist
. 5
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): 4 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440
t5ins.doc•rev.6116 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
M 251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 01/13/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupiedDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of designflow(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.doc•rev.6/16 Title 5 Official Inspection Form: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
251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma: 02635 07/13/2017
page. CityTrown State Zip Code Date of Inspection
D. System Information (cost.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
1
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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
k 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.doc•rev.6/16 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
°M 251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is Cotuit Ma. 02635 07/13/2017
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
05-23-2011
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 36"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: 24"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
' Dimensions:
Standard H-10 1500 gallon septic
tank
Sludge depth:
1°
t5ins.doc•rev.6/16 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
251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
page. City/Town 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
36"
Scum thickness
1
511
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined?
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The
Sandwich Health Dept. has a list of local septic pumping co.
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site planj:
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.doc•rev.6/16 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
251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The H-10 D-Box had no visible signs of leakage or evidence of past 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.):
* 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.doc-rev.6/16 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
GSM ,a''v 251 School Street
Property Address
Caroline Tarolli
Owner Owners Name
information is required for every Cotuit Ma. 02635 07/13/2017
mom
page. City/Town State' Zip Code. Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers. number: 3 -
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection there were no visible signs of past hydraulic failure.
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
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4„M
251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
_
page. City/Town 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is Cotuit Ma. 02635 07/13/2017
required for every
page. City/Town 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
r
�$•
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
TOWN OF BARNSTABLE
LOCATION SEWAGE# a?6//—I—IT
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type). llio so. '(size) /o"r 3 d
NO.OF BEDROOMS
OWNER
PERMIT DATE: S' }��// COMPLIANCE DATE:
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 l
�a
t A
114
•
t_/ah
'. E 7L�•log � � �
' Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is required for every Cotuit Ma. 02635 07/13/2017
page. Cityrrown 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: 14 plus feet
' feet
Please indicate all methods used to determine the high groundwater elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augered a hole at a lower elevation and shot it with a transit to show five plus feet of seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
• ' Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
251 School Street
Property Address
Caroline Tarolli
Owner Owner's Name
information is Cotuit Ma. 02635 07/13/2017
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
lye
/ya H zv
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable Health Inspector
Ft y Reg ulator Services lZ�1l' Office Hours
oti 8:30-9:30
o„ Thomas F.Geiler,Director 3:30-4:30
BARNSTPA13M i Public Health.Division
MASS.
9 1639. A�O� Thomas McKean,Director
�ArfD MA'S `
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 _ _ Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT SEPTIC QUESTIONNAIRE
Date:May 29,2013
1. General Information: Size of Property.46 acre
Address: 251 School Street Cotuit,MA 02635 Map and Parcel Number 020-100
Name: Caroline Tarolli Phone#: 978-314-8473
2a. How many bedrooms exist at your property now? 31
2b. Are you planning to add any bedrooms? No changing bedroom three to accessory apartment If yes,,how many?
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?3
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing
rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways.
Please label each room clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is connected to public sewer, skip questions#4 through#9 below. ,* .
+ c�w
4. Location of dwelling is INSIDE a Saltwater Estuary Protection Zone?
kw✓' t .�
5 . Location of dwelling is OUTSIDE a Zone of Contribution to public supply wells?: = : -
6. Is the dwelling connected to an PUBLIC WATER?
7. Is a disposal works construction permit on file? YES ) Q r,
8. If yes,how many bedrooms were.approved according to this permit? Bedrooms.
9. Were any building permits obtained for construction of additional bedrooms?. ` YES or. 'a NO .111
10. Is there an engineered septic system plan on file at the Health Division? YES or No',
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
----------------------------------------------------------------------------------------------------------- --- _ w
F,�t OFFICE USE ONLY ]
The Public Health E�vision has no objection to bedrooms at this prope . 2 O
Special Conditions: Ex e5 c fSe P-oo-, w"Sr 0 lie L4-k I I
Signed: Date:
f
McKean, Thomas
From: McKean, Thomas
Sent: Wednesday, July 24, 2013 9:27 AM
To: Dabkowski, Cindy
Subject: RE: 251 School Street Cotuit Amnesty Applicant
I received it. It will be approved for three bedrooms maximum. I'm concerned about the private 18' X 11""exercise
room" in the basement, which has a door to the entrance-way. I suggest a three bedroom deed restriction be recorded.
Will you require a restriction?
Tom.
-----Original Message-----
From: Dabkowski,Cindy
Sent: Monday,July 22, 2013 1:55 PM
To: McKean,Thomas
Subject: RE: 251 School Street Cotuit Amnesty Applicant
The floor plans were submitted to me on 11 X1 7 paper, therefore I sent to you via interoffice mail. I will put a second
set in the interoffice mail today,
Thank you Cindy Dabkowski
-----Original Message-----
From: McKean,Thomas
Sent: Monday,July 22,2013 1:48 PM
To: Dabkowski,Cindy
Subject: RE: 251 School Street Cotuit Amnesty Applicant
Sorry- I haven't seen that one yet.
-----Original Message-----
From: Dabkowski,Cindy
Sent: Monday,July 22, 2013 11:58 AM
To: McKean,Thomas
Subject: 251 School Street Cotuit Amnesty Applicant
Hello Mr. McKean
Did you receive a request for Amnesty Approval for 251 School St Cotuit, MA
Cindy Dabkowski
1
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION &C.li d0 cT SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL .O Dt 16
INSTALLERS NAME&PHONE NO. A f �7�., 7
SEPTIC TANK CAPACITY
LEACHING FACILITY:( 4 lfio Sow (size) /o 'V 3 d
NO.OF BEDROOMS
f OWNER
PERMIT DATE: 3 // COMPLIANCE DATE:
Separation Distance Between the: o
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
3
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=020100&seq=2 5/29/2013
r TOWN OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY SV(D i6
LEACHING FACILITY.(type) )ris 41 C 3 ff/o Sow (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: 5- �� 3 _ COMPLIANCE DATE: '
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 t '
within 300 feet of leaching facility)facili Feet
FURNISHED BY
�A Sl:L •,
l.� S7'.0
z_SL
7G bu
Q J
co
No. le—1 u S V Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for Bispbsal *pstrm Construrtiou prrmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.,,f �e�-o 6L s Owner's Name,Address,and Tel.No
Assessor's Map/Parcel oXnt9(�-(� ,(� �a � (O 5� �9
Installer's Name,Address,and Tel.No.7749-,-Fj- 6 a-77 Y Designer's Name,Addre Tel.No.
�/4Sdh sdUZG,-
YI /� Z6.4,
x e
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 j gpd Design flow provided l gpd
Plan Date Number of sheets Revision Date
Title
r
Size of Septic Tank Type of S.A.S.
Description of Soil
r
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 y rd of Health.
Si Date e1
Application Approved by Date 43 11
Application Disapprov y Date
for the following reasons
Permit No. Z,D[j— �SS Date Issued Z3 I 1
.�`— R
Fee
` THE COMMONWEALTWOF MASSACHUSETTS Entered in computer:
�UBLIC HEALTH DIVISION - T �YVN OF BARNSTABLE, MASSACHUSETTS _;Fs
r
2pplication for Nispblal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 6L n Sr Owner's Name,Address and Tel No
Assessor's Map/Parcel 0,0W .4
Installer's Name,Address,and Tel.No. 77y,.f 61- 7 / Designer's Name,Andres Tel.No.
IJAS� (!/vn 7—6, • SU S l rk l l ` 110 ec r.,-
tia�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures r�
Design Flow(min.required) ?j(� gpd Design flow provided J y gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
,r
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected.
Agreement: }
The undersigned agrees to ensure the construction and mairrtenance 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 thi-s'Bo rd of Health.
Si _ Date
Application Approved by - Date _; 11
Application Disapprove y Date
for the following reasons -
Permit No. ;_70( �— Sy Date Issued `J -3 I ��
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned
at ` C/ G C j" e(5 '- has been constructed in accordance
with the provisions of Title and the for Disposal System Construction Permit No.?DI I- 158 dated Z 1
Installer:�J,4-•S`1 n22l Designer „
#bedrooms J Approved desgf�fl�w 3Yd gpd
The issuance of his p it shall not be construed as a guarantee that the system will functioon'as designed. /
Date I 1 Inspector
Zo
--------- '- -_----�-----.--------------- ----------------------------------------------. ----,-_ ------ ._ -_-.---------
No. Fee--
ee 5 ('
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction permit
Permission is hereby granted to Construct( Repair( ) — Upgrade( ) Abandon( )
System located at p�S/• �C/ >L
(*76-?Qr/ l
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date 5 Z3 I I Approved by _
r
THE FOLLOWING
IS/ARE,-' 'THE BEST .
IMAGES- FROM POOR,
QUALITY ORIGINAL (S)
I m
DATA
7 , d
Town of Barnstable
�.►+�► Regulatory Services
�,. Thomas F. Geiler,Director
snaxsrnaM
MASS, Public Health Division
9q'ArFp3 `�� Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
,=&� -
Date: '3 i-L"' Sewage Permit# Assessor's Map/Parcel Zo Sa o
Installer & Designer Certification Form
Designer: Installer: ) ►�SV
Address: Z(,O 6SAvA%cs-&\ V\ICO WAY Address: 600�Vj "ROP03
On 2 3 1 it AME UA Va ���• was issued a permit to install a
(date) (installer)
septic system at Zyl S(�4�voL S-t2><�-t, Co�u �"T based on a design drawn by
(address)
dated �44 Z3 i ti6k1
y / (designer)
V I certify that the septic system referenced above was installed substantially.according to,
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. . Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation opthe (
r any vertical relocation of any component
of the septic system) but in accordatate & Local Regulations. Plan revision or
certified as-built by designer to > tut(if required) was inspected and the soils
were found satisfactory. 9�
ITS,
1P5°� SovZA �r JOHN G. GN
(Ins ler's ture) SCHNAIBLE
t - 13 -IZ �
�No. 1017Q
� �GrSTER�
(Designers Signature) (Affix Design ere)
PLEASE TURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
q:\office forms\designercertification form.doc
� r �
��` �, _
Please
Sign
'P(off:_-i� C i .� `� 7 , d
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
MAS& Public Health Division
039. `� Thomas McKean,Director
RFD Mld A
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: �ANuaR`f 13,Z6+7- Sewage Permit# Assessor's Map/Parcel 20 Imo"
Installer & Designer Certification Form
Designer: (A• Installer: �P�tGQ,6(A� �X�A�/prtta(� Gora`CRnc i o�S
Address: Z(o 0 V\k 4WAI Address: C o`J uXT� 'Ro>A';J
On J 3 1 AMsQ,\LA�1 was issued a permit to install a
(date) (installer)
septic system at C;vu --V based on a design drawn by
(address)
dated f'Wi z3,1AA
y / (designer)
V I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if required) was inspected and the soils
were found satisfactory.
,,SH OF MAssgcti
1FaSo-4 SpvZA �i JOHN G. �s
I(Ins'rafflferes ture) SCHNAIBLE N
No..1017
1oUu �L�iyI��G3�C. s�c'�STEa``�
(Designer s ignature) (Affix Design ere)
PLEASE�ETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
q:\office fonnAdesignercerti6cation form.doc
Town of Barnstable Po 13/u 7
Department of Regulatory Services
nARNSTA6LE, : Public Health Division Date
MAS&
1639. �e� 200 Main Street,Hyannis MA 02601
Date Scheduled o o Time . f Fee Pd. (a
oil Suitability Assessment for Sewage ispo al
Performed By: y�k`_ Witnessed By: C�v W ✓ n / .
LOCATION&GENERAL INFORMATION
Location Address Owner's Name
Address BLS 1 ,S�c001--�� GbU
Assessor's Map/Parcel: 00 Q O Engineer's Name CC)
NEW CONSTRUCTION REPAIR pTelephone# dTj ^Z�5 ui� 1
Land Use ���jr (]�J_\\\ P� Slopes(%) O Surface Stones
Distances from: Open Water Body 1-0 ft Possible Wet Area 11:�0 ft Drinking Water Well 'Wb ft J,
Drainage Way L "� ft Property Line — ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
' .
VJ.
Efl
vlei
Q
.�
w
I CD 1
l,(acn i�1-' .
Parent material(geologic) Depth to Bedrock
Depth to Groundwater:'Standing Water in Hole: Q� Weeping from Pit Face a+J
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_
,fir {1
FERCOLY 1 ION l EST U 1tE i t 7
Observation
Hole# Time at 9"
/t w
Depth of Pere �0 Time at 6"
Start Pre-soak Time @ rt Time(9"-6")
End Pre-soak
Rate Min./Inch Z'
Site Suitability Assessment: Site Passed_ Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
LPt^
n
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
l Consistency,%Gravel
DEEP OBSERVATION HOLE LOG Hole.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) j (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Graven
rI,1
s
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes X
Within 500 year boundary No X Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervi us material exist in all areas observed throughout the
area proposed for the soil absorption system? W-�
If not,what is the depth of naturally occurring pervious material?
Certification /
I certify that on ��`' ' ate)I ha, a ss d e it evaluator examination approved by the
Department of Envir ental rot ction an t at th`e bove nalysis was performed by me consistent with
the required training, x ertise d experienl descrs din 10 CMR 15.017.
Signature Dater(
Q:\SEPTIC\PERCFORM.DOC
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008.
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the,end of the form.
Important:When filling out A. General Information
forms on theZ J
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini :I
.cursor-do not use the return Name of Inspector
key. Capewide Enterprises,LLC.
Company Name
t
t� P.O.Box 763
Company Address ! �
t .ri
Centerville Ma. 102632
rerwn City/Town State /Zip CodA
(508)428-4028 S14454 -;
Telephone Number License Number Cam'!"x3x
w
A
B. Certification
I certify that I have personally inspected the sewage disposal system at this a dress and that-the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ;; ❑ Conditionally Passes ❑ Fails
❑`4Needs Further Evaluation by th&Local Approving Authority
10/27/2008
Inspector's ignature V Date
The system inspector shall submit a copy of this inspection report to the Approving'Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
. U�
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is Cotuit Ma. 02635' 10/27/2008
required for
every page. City/Town 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:
Z 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:
The septic system is in proper working order at the present time.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2
t ;
Commonwealth of Massachusetts
W Title 50ffiaI Inspection ection Form
c p
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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):
t ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3
J I iil
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�^M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008 .
every page. City/Town 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".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified 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
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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008
every page. City[Town 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
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is Cotuit Ma. 02635 10/27/2008
required for
every 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?
El ® 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
El 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 of issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008
every page. City/Town State . Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1500 gallon septic tank;Distribution box and two 500 gallon Leaching
Chambers.
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? ® Yes ❑ No
Seasonal use? ' ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2007:27,000
9 ( Y 9 (gpd)): 2008:28,000
Detail:
2007:74 gpd 2008:77 gpd.
Sump pump? - ❑ Yes ® No
10/27/2008
Last date of occupancy: 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008
every 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:
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008
every page. City/Town' State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Septic system installed in 1997
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
14"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallon
Sludge depth: 8..
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is Cotuit Ma. 02635 10/27/2008
required for
every page. City/Town 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
24"
9..
Scum thickness
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
6"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet teesw are in place.No evidence of leakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
i
❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is Cotuit Ma. 02635 10/27/2008
required for
every page. City/Town 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.):
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•09/08 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma: 02635 10/27/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level,above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 gl. LC
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Leaching chamber had V of water at time of inspection
with a stain line 18" below invert.
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
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
251 School Street.
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008
every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14
Map Page l of 2
Town of Barnstable Geographic Information System
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http;//www.town.barhstable.ma.us/arcims/appgeoapp/map.aspx?prope,rtyID=020100&ma... 10/29/2008
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008
every page. City/Town 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: Bottom of LC 20'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of-
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16
i
f
Commonwealth of Massachusetts
.Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 School Street
Property Address
Rosemary Landry+ Elizabeth Rice
Owner Owner's Name
information is required for Cotuit Ma. 02635 10/27/2008
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness.Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
❑ System Information— Estimated depth to high groundwater
r
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r
TOWN OF BARNSTABLE
iK G 2
L 0 C P r 10N 0s( SEWAGE #
V IAGE ASSESSfO�R'S, MAP&LOT 610- )00
INSTALLER'S NAME&PHONE NO.�� /� z ✓' �SF�
SEPTIC TANK CAPACITY ��®a
LEACHING FACILITY: (type) 02 L )q 6WM&5 (sized
NO.OF BEDROOMS
BUILDER OR OWNER � 9
PERMTTDATE: O "�Z.! COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any.wells.exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
PAJI
'�-Vye
�r
No. Fee tc
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYtcation for ltgpogal *pgtera Congtructton Vermtt
Application for a Permit to Construct( )Repair(/SUpgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
C10YU117 R t L 4 qal41
Installer's Name,Address,and Tel.No. I l/` ++°' -C(p Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow � gallons per day. Calculated daily flow 7315 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description
P�of Soil 04CM /0M, Z /QG� C TUJ,6 Oy 7'' 6v a
Nat r of Repairs or Alteration (Answer when
en a plicable) �� d� 300
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 iron ntal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue t 's Bo f H
Signed Date
Application Approved by Date
Application Disapproved for the fWowinYreasons
Permit No. Date Issued
---�.._ — •w�ae.... .
er:
No. - ��Fee '
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
- 01poYication for Miopozal 6pztem Congtructi.on Permit {
Application for a Permit to Construct( )Repair(..,05 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. P" 5000L 5 7 1 Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel `'" L1
Installer's Name,Address,and Tel.No. 116/�-Cbe Designer's Name,Address and Tel.No.
1 * � 4 /C�
Type of Building:
Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures .. .
Design Flow `®° gallons per day. Calculated daily flow ��47f5 gallons.
w - q
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. �`
Description of Soil n -r�lei a ��� /a -0 0� `�r�+'I a�7#-� La- /��
Nature of Repairs or Alterations(Answer when applicable) 5Skk~ Z'5r2d /i1 ; moo
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 theAnvironmental Code.and not to place the system in operation until a Certifi-
cate of Compliance has been issued*15y this Board/of Hg f
Signed Date _ ^
Cl
Application Approved by Date —
Application Disapproved for the owi reasons
a
, Permit No. -7— 2a Date Issued ~`
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( )
Abandoned( )byrce,c,
at U has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system 1 function as designed.
Date Inspector
No. Fee---1------------------------------ — -
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Miopool *pgtem Construction permit
Permission is hereby granted to Construct( )Repair� Upgrade( )Abandon( )
System located at_ 2L 5� / <' .. P-1 cr WT�&
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: �-- _ 9 `7 Approved by
�. 4' y
NOTICE: This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR_A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for•dispp`salworks
construction permit,signed by me dated —� _Cr) , concerning.the.
.property located at / � )� �(J� -meets all of the
following criteria: f
• There are no wetlands within 300 feet of the proposed septic system
• There 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 ,
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE: 965q,
LICENSED SEPTIC SYSTEM ALLER 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].
\ f
aru
D b`.'
/ 1
i
Town of Barnstable Health Inspector
Office Hours
OptFlE r Regulatory Services 8:30 7 9:30.
Thomas F.Geiler,Director `3:30—4:30 '
BARNSTABLE, * Public Health Division
MAS
S.
ft
039• �m Thomas$ McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304 • '
AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE-
} Date:May 29,2013
1. General Information: Size of Property.46•acre
Address: 251 School Street Cotuit,MA 02635 Map and Parcel Number 020-100
Name: Caroline Tarolli Phone..#:`978.314,8473"
2a. How many bedrooms exist at your property now?3 • ,
2b. Are you planning to add any bedrooms?-No changing bedroom three to accessory apartment If yes,how many?
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?3
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing
rooms in the home and the proposed amnesty apartment. 'Provide width measurements of any open+doorways. r
Please label each room clearly. 4
3. Is the dwelling connected to public sewer? NO ,
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4 Location of dwelling is .INSIDE -a Saltwater Estuary Protection Zone?
5 . Location of dwelling is OUTSIDE a Zone of Contribution to public supply wells? '
a
6. Is the dwelling connected to an PUBLIC WATER?
7. Is a disposal works construction permit on file? - YES
8. If yes,how many bedrooms were.approved according to this permit? 4 Bedrooms. -
9. Were any building permits obtained for construction of additional bedrooms? YES or NO
10. Is there an engineered septic system plan on file at the Health Division? YES 'or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two years?' 'YES or " NO
-----------------------;----------------------------------------------------------------------------------
FOR OFFICE USE ONLY '
The Public Health Division has no objection to bedrooms at this property. -
Special Conditions:
Signed: Date:
AsBuilt i Page 1 of 1
TOWN OF BARNSTABLE
LOCATION SEWAGE# -76 1/-/.J`-F
VILLAGE ASSESSOR'S MAP&PARCEL<<Q 'd t`
INSTALLERS NAME&'PHONE NO. /n f� A z� 3 7 r/,P Zg-�:r y
SEPTIC TANK CAPACITY l.SU D G, 14,, % i 6
LEACHING FACILITY:(type). /•i'e lc� �� ffio Sow (size) /o �+� 36
NO.OF BEDROOMS �.
OWNER
• PERMIT DATE: 5' -3' /!/ COMPLIANCE DATE;
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 A
FURNISHED BY
r
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. LE:Y-1 I r ' APVNOVEo BY: ORAWN BY - .
DATE: 2 20 12r REVISED
251 5 c ti Dot_ �i-1zE8'I" °
Lo—'vt t' M
I Lo WE;1� L.M.2 ROD M ar.Wn.c N�MBEg
OASTAL
DEEP OBSERVATION HOLE LOGS
NGINEERING
NO SCALE P 13147
DEEP OBSERVATION HOLE 1 EL. = 91.8f DATE OF TESTS: DECEMBER 10, 2010
SCHOOL ST MPANY, INC.
d
DEPTH FROM SOIL SOIL SOIL COLOR SOIL OTHER PERCOLATION RATE : LESS THAN 2 MINUTES PER INCH DROP -4 260 Cranberry Hwy.Orleans,MA 02653
SURFACE HORIZON TEXTURE MUNSELL MOTTLING IN THE C HORIZON
0" -12" A LOAMY SAND 10 YR 3/2 NONE WITNESSED BY : JOHN G. SCHNAIBLE, CEC 2 s08.255.6511 Fax:s08.255.6700
DAVID STANTON HEALTH AGENT 0
12" - 27" B LOAMY SAND 10 YR 4/6 NONE NO GROUNDWATER ENCOUNTERED Y
27" - 132" C MED. SAND 10 YR 6/6 NONE LOOSE c �'
as
TO COARSE
SAND
BARNSTABLE (COTUIT), MA
DEEP OBSERVATION HOLE 2 EL. = 90.5t AM
KEY MAP
DEPTH FROM SOIL SOIL SOIL COLOR SOIL OTHER ti r 7 Y �� NO SCALE
SURFACEHORIZON TEXTURE MUNSELL MOTTLING
" " EXISTING,CQNCR�Tfr ,.
0 - 12 A LOAMY SAND 10 YR 3/2 NONE
/ x99. pq�O WALK TO BE,REMOVED..
w
12" - 30" B LOAMY SAND 10 YR 4 6 NONE
30" - 132" C MEDIUM TO 10 YR 6 6 NONE LOOSE ,i % _: ,._� wv
` PLAN REFERENCES: {
/ PERC AT 90 / ; x99.2• .
COARSE p
SAND / c �►�,y /�y`y ASSESSORS MAP 20, PARCEL 100
•6.Wti. z '.4• .� . 'µme A`'•,.�1>\ i 'e-•1
/ xsa x97,2 t �, , PLAN BOOK 15, PAGE 67
ASSESSORS MAP 20 _ F ` g
PARCEL 101 .. :w y : ., ' DA TUM NO TE.
DESIGN CALCULATIONS / h��,, ' ` ELEVATIONS SHOWN HEREON ARE BASED
�� 'x ON AN ASSUMED DATUM
/ x97.7 EXISTING
DESIGN FLOW: PROPOSED 3 BEDROOMS AT 110 GAL. PER DAY PER BEDROOM = 330 GPD (PREVIOUS HOUSE-3 BEDROOMS) �� 10" MAPLE TO CONCRETE WALL
330 GPD X 200% = 660 GALLONS USE 1500 GALLON SEPTIC TANK, MIN. ALLOWED :` (i! BE REMOVED 96 _ TO BE REMOVED
A 30'L. x 1O'W. x 2'D. LEACHING CHAMBER CAN LEACH: x9 ,4 a
��` }' �� �� � ` ' EXISTING DWEW G x95.8
Vt = 30 ( 2 ) 2 x .74 + 30 ( 10 ) x .74 + 10 ( 2 ) 2 x .74 = 340.4 GPD E>usTlNc CONCRETE �� "k ��� ,� To BE REMOVED F
�,. � c
BLOCK FOUNDAION TO r EXISTING PICKET LEGE�l D
8E REMOVED � `� ,a', � � FENCE TO BE (,� /Y J
INSTALL: ONE ( 1 ) - 30'L x 10'W. x 2'D. LEACHING CHAMBER Vt = 340.4 GPD > 330 GPD REQ'D. REMOVED
ONE ( 1 ) - 1500 GAL SEPTIC TANK, MINIMUM ALLOWED r' 'x95 N rl
ONE ( 1 ) - DISTRIBUTION BOX ( 5 OUTLET) (H-10)
CONCRETE SEPTIC COVER
tk
wv
100' BUFFER FROM ' I r' \ ~/ c�.fpR� i � 9 WATER VALVE
NOTES EDGE OF WETLAND I 00 - �0 %�_-; �' PROPOSED SEAL
1 GARBAGE GRINDERS ARE NOT ALLOWED WITH THIS DESIGN. \ RETAINING WALL
-O- UTILITY POLE
I I 90.8 \ " s �"• F` (TOP OF WALL
2) THE INSTALLER IS RESPONSIBLE FOR ASSURING THAT COMPONENTS OF `I ♦ \ (STING SHEDS . HEIGHT VARIES) EDGE OF WETLAND `?NOFti�gs
THE SEWAGE DISPOSAL SYSTEM ARE DESIGNED WITH SUFFICIENT ♦ T REMOVED sq�
STRENGTH TO SUSTAIN ALL LOADS TO BE IMPOSED ON THEM. ANY I ♦ PR�OSED /
I I ♦ EXISTING SEPTIC m WETLAND FLAG o SCHNA G
COMPONENT OF THE SYSTEM SUBJECT TO VEHICULAR TRAFFIC MUST I I I RETAINII� / / SYSTEM TO BE
COMPLY WITH A MINIMUM STANDARD OF A.A.S.H.T.O. H-20 WHEEL LOADS. 'I ♦WAL 9 / �� REMOVED -- FENCE (TYPE AS NOTED)
0. 101
50 BUFFER FROM I I (TOP OF WALL / F �o
3) PRIOR TO SET
ANY SEWAGE DISPOSAL SYSTEM COMPONENT, INSTALLER EDGIE OF WETLAND I 1 I \`90AEIGHT VARIES) PROPOS / aN
SHALL VERIFY EXISTING CONDITIONS, INCLUDING ELEVATIONS OF EXIT INVERTS, I ��l _ y w- WATER LINE N�7A P
AND REPORT ANY DISCREPANCIES TO THE DESIGN ENGINEER. I 14 1 \ D B� A. ! :
` I77.$ I I as � ♦ x90.8 AssEssoRs MAP 20 X 92.8 SPOT GRADE
4` ,",LL GEL,;:"T`. .,C`j��^ ICI?E SI!A;L RE A" nle• rCH 40 PVC UN ESS OTHERIMSE
111 PARCEL 99
1 NOTED. THE MiN;ZM SLOPE OF 4' LiA. SCH 40 PVC SHALL BE 0.01 FT/FT. I I I °° '**, -
5 NO PART OF THIS DESIGN SHALL BE ALTERED WITHOUT PRIOR APPROVAL ` I I \ ` ♦ OSEDxso• ® O i / -10- - �.,COIVTOUR ,fi
i
FROM THE DESIGN ENGINEER AND THE AGENT OF THE LOCAL BOARD OF � I I \ '�� GALLON
HEALTH. ALL REQUESTS FOR CHANGES SHALL BE MADE IN WRITING PRIOR I I I I 1 ` C..P11C STANK / 94 >>,
I ♦ PROPOSED 30'L x 10 W x 2'D
o
TO CONSTRUCTION. \ ` I I 1 87.51 � � j�.
I I o I \ I O LEACHING CHAMBER
6) THE USE OF ALTERNATE MANUFACTURERS FOR SYSTEM COMPONENTS I \ 1 I BENCHMARK-ROD CAP off / ,A• .T w j
SHALL NOT BE APPROVED IF THE USE OF THEIR EQUIPMENT REQUIRES �� \ \ \ \ SET IN LAWN-EL=90.17
CHANGES IN DESIGN. [�1 l
\ \ \ \\ \ (SEE DATUM NOTE) RESERVE ! / FILTER FABRIC 1" x 2' x EN ^ ►"'1
7) THE INSTALLER SHALL ASCERTAIN THE LOCATION OF EXISTING UNDERGROUND \ tp� s
UTILITIES PRIOR TO EXCAVATION, AND SHALL PROTECT UTILITIES WITHIN THE `� \ \ \ \ \ ` ♦ AREA / STAPLE FABRIC STAKE 6' ON CENTER F..�
� rn \ \ \ � pc ;% TO POST. (MAX.)
WORK AREA DURING CONSTRUCTION. 4 i \
8) THE EXISTING SEWAGE DISPOSAL SYSTEM (INCLUDING CESSPOOLS) SHALL BE t \\ cn
A
\\ \\\\ \ \ \AOF • PROPOSED LIMIT OF as.s
PUMPED, FILLED WITH SAND, AND ABANDONED; OR SHALL BE REMOVED \ \ �, \ $� \ li` ♦ WORK/SILT FENCE w
NTH SURROUNDING CONTAMINATED SOILS AND BACKFILLED WITH CLEAN '� \ \ \ `�� �, A
SHED SLOPE
F--1
COARSE SAND. \ �
9) ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING TAPE � \\ \\ \ � _ - 88
OR A COMPARABLE MEANS IN ORDER TO LOCATE THEM ONCE BURIED. �,\ \ \ \ ��, 0' \ Cl \ /
\ \ \ \ BURY BOTTOM OF
IF APPLICABLE: �. \ \ ' FILTER FABRIC IN
10) FILL MATERIAL FOR SYSTEMS CONSTRUCTED IN FILL SHALL BE CLEAN SIEVE PERCENT \ \ ASSESSORS MAP( 20 \ \ 6' x 6' TRENCH
GRANULAR SAND, FREE OF ORGANIC MATTER AND OTHER DELETERIOUS SIZE PASSING x68.0 \ \ \ P,�L 97
MATERIALS. THE SAND SHALL BE GRADED SUCH THAT NOT MORE THAN
45% OF THE SAMPLE, BY WEIGHT, SHALL BE RETAINED ON THE #4 SIEVE. 4 100% \ \
THE FILL SHALL NOT CONTAIN ANY MATERIAL LARGER THAN 2 INCHES. 50 10%_100%
THE MATERIAL THAT PASSES THE 4 SIEVE SHALL MEET THE 1120000 00 5 _ xt.6% \, \ \ \ ' 86.6 / O
FOLLOWING GRADATION REQUIREMENTS: ONE (1)- 30'L x 10'W x 2'D LEACHING CHAMBER CONSTRUCT
BY PLACING THREE 8'-6" x 4'-10" x 2'-10" LEACHING SILT FENCE DETAIL j
CHAMBER UNITS END TO END WITH 2'-3* STONE ON ENDS AND PLAN NOT TO SCALE w
2'-7" STONE ON SIDES. USE 500 GALLON LEACH CHAMBER
UNITS AS MANUFACTURED BY SHOREY PRECAST OR EQUAL). 20 10 0 20 60 w O
TOP OF FOUNDATION EL 100.00 I
TOP OF SLAB 91.00 v�
RAISE COVERS TO WTHIN 6' ;(�Ax C �J r^ 0 a i
RAISE COVER TO WIIHIN 3 w
OF FINISH GRADE L- =V', �1 .`? - OF FINISH GRADE O
FINISH GRADE-,. >< inch = zo r1w INSPECTION NOTE u F
9' MIN, (THIS AREA IS SERVED BY TOWN WATER) CIO
THE STATE ENVIRONMENTAL CODE TITLE 5, w
REQUIRES INSPECTION(S)
3' MAX. D'BOX MINIMUM D'SOX INS OE '�✓' p ` , a cv rn
'C-T' z:.. MENSIONS 12•x12' 3 OF THE SEWAGE DISPOSAL SYSTEM BY THE DESIGN ENGINEER.
4" DIA SCH 40 PVC PIPE DROP-2" MIN - 3' MAX. INSTALLATION CONTRACTOR MUST NOTIFY THE DESIGN ENGINEER SCALE
FLOW LINE 4' DIA SCH 40 PVC PIPE fM�T „ 4' DIA SCH 40 -IV'C PIPE 1/8�T0 • STONE D'BOX PRIOR TO THE START OF INSTALLATION FOR DISCUSSION ON AS NOTED
DRAWING FII,E i
10• Sm eam 2,-0. REQUIRED INSPECTIQNS. C17347.dw !
a uauo o" PIPE OR FLOW
g
DATE
5-17-11
M 88.75 88.25 1500 GAL � LEVELER INVERT ALL ,�. EFFECTIVE �
�"�," ' ,�' DEPTH NOTE:
M W/SANITARYSEPTIC �TEES 87.90 87.80 _ 5 87.63 87.50 3/4' TO 1 1/2'
ALL INV. THE INFORMATION HEREON HAS BEEN PREPARED ACCORDING TO DRAWN BY
^o DOUBLE WASHED STONE I01
N •� COMPACTED BASE N THE REQUIREMENTS OF TITLE 5 OF THE STATE ENVIRONMENTAL � P
THE MINIMUM SLOPE FOR W/ 6 LAYER OF CODE FOR SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND CHECKED BY
a' olA SCH•40 PVC CRUSHED STONE ALL
4'-10' LOCAL BOARD OF HEALTH REGULATIONS.
PIPE IS 1/8 PER FT COMPACTED BASE GAS BAFFLE USE 0 - NJ 0 0
._ . o ...
W/ 6' LAYER OF 'TUF-TITS' OR LINE(S) EXITING D'BOX MUST REMAIN ^ N
t< CRUSHED STONE APPROVED EQUIVALENT LEVEL FOR 2'-0' BEFORE PITCHING END VIEW �//iv O
DOWN TO LEACHING FACILITY
v OUTLET TEE DEPTH 10't 12't
40 t LIQUID DEPTH BELOW FLOW LINE ESTIMATED DEPTH
TO GROUNDWATER IS > 20 FT qw Op Mq I
4 FT 14 INCHES 5 FT 19 INCHESH-10 LOADING LONITEST RUN y THE LOT SHOWN HEREON IS AS DESCRIBED ON �� Ss9Oti vC2elel
6 FT 24 INCHES PLA;V BOOK 15, PAGE 67. oho J�HN �� eo
v 7 FT 29 INCHES DEMAREST JP, N
SCHEMATIC FL O w PROFILEDETAIL OF LEACHING CHAMBER , �oNo.36859,
PLS DATE SAn ( 1 �gNFESs��y w I OF i SHEETS
ALL INSTALLATIONS MUST CONFORM TO THE MINIMUM REQUIREMENTS OF TITLE 5 �sURVE PROJECT NO.
w v C 17347.00
►19 �)GA 6
•