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Home My WebLink About0173 THANKFUL LANE - Health 173 THANKFUL LN LA = 9 - 023 i i Commonwealth of Massachusetts D 39rb �3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 173 Thankful Lane � Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Na"� information is Cot-it y MA 02635 05/04/2021 required for every -page. City/Town State Zip Code Date of Inspection r 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 Ins. ector Information filling out forms A P on the computer, use only the tab Michael T Bisienere- key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key-'. ................... 52 Rivers End Road Co r� Company Address Teaticket Ma. 02536 Citylrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 05/04/2021 _._.__. .. Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r A Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owners Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Please read the bottom of the first page of this report. This statement is from the Ma. DEP. This home was inspected under the Ma. DEP and The Town of Barnstable's guidelines. This 3 bedroom home has an H-10 1000 gallon septic tank feeding a precast leaching pit with stone. At the time of the inspection there was ponding water in the leaching apx 13" below the invert and no visible failure criteria was found. Tank was scheduled to be pumped after the inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 ,page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND below): (Explain ❑ 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): 1 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name I information is:required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed i . N p pe(s) umber of times pumped: ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5ins.o.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,b 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under.Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on' ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 plus GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage town water 9 ( Y 9 (9Pd))� Detail: In 2020-72,000 gallons were used and in 2019-43,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: , Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Tank was scheduled to be pumped after the inspection. Was system pumped as part of the inspection? ❑ Yes ❑ No If yes,volume pumped: gallons How was quantity pumped determined?_ Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (Yes or no) (if yes, attach previous inspection records if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 14"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments(on condition of joints, venting, evidence of leakage, etc.). Water was flushed and came freely. t5ins?.doc•rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is . Cotuit MA 02635 05/04/2021 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 6"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: H-10 1000 gallon Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 13" 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 recommend the new owner have the tank and the leaching pumped annually with a local septic pumping co. At the time of inspection the liquid level was at working level and the baffle was in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: Y❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST , Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code, Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes . ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): I ran a camera down the discharge pipe and did not see a D-Box. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessment 9 P Y rY s 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" • I Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the liquid level was apx 13" below the invert and no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): �I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owners Name information is required for every COtUIt MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r o/ t5insp.doc•rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show four plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Thankful Lane Property Address CARRIE S MALEK-CICCONE NOM TRUST Owner Owner's Name information is required for every Cotuit MA 02635 05/04/2021 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 v ' MAP SKETCH ADDENDUM Borrower/Client CIC'ODNE• CARL & CARKE PmportyAddress 173 TEANKF'UL,L LANE city O01= County BARNSTABLE State MA Zip Code 02635 Lender BUILDING SKETCH :. . . .......:...:.......... ..>.......... .:.......... . . . . . . . . L ...:... . . . . . . . . . . . . . . . . . . . . �.T.l ::: ....;..:...:...:..<...:...:... . . . . . . . . . . . . . . . . . ........... ...:..:..:: : ..: : : . . : . .... .........:.. . .......;.. . . .. . . . ........... : . . . . ....... . . . . . . . . . . .........:.. . : : . . ..;...:...:...:..;... . :...:...:...;..:...:.....:...:......:... 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L � . ww��.w�• .��.. maw..w, .w w�. wwww,�..�+mow t'O.CAT10 I-7 � SEWA'GE� PERMIT -NO. flecVILLAGE I N S T A LL�iER'S NAME & _ADDRESS B UILDE R // OR OWNER 771 l7 d yvi -t -7 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 7—( ••a� �� 1.� • 1 ._. � �' �I �� _ ' , No........... :r.T.. F Fmc......................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 7`'a"A7� . 3trtttt�n for UIipnsFal Works Tongtrurtion throat i f �h q -Applica on is hereby made for a Permit to Construct ( ) or Repair ( ) an I ivi 'ewage Disposal System at: _ ____ _ . k ... .................. % :. . r� — Lo tion-Ad e - •--N •- • d.�L i.a - ......... ............ �:! !.`�_....._� l..C�-. . ��- . ......rs?-••--•............... Owner Address ................................................ ............................................. ................................................... Installer Address Type of Building 5 Size Lot.. ®....Sq. feet U Dwelling—No. of Bedrooms......... ................ .Expansion Attic ( ) Garbage Grinder ( ) �+ Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixture........................... Design Flow................. �.----------------gallons per person of day. Total daily flow_-__•----_- rjpc�-/, WSeptic Tank—Liquid capacity` .gallons Length. .. ��Width...�e.-l®_ Diameter________________ Depth_.. x Disposal Trench—No..................... Width.................... Total Length___--- - - Total leaching area....................sq. ft. Seepage Pit No.............�___. Diameter.._... . .. Depth below inlet_...... .,S ... Total leaching area... ..sq. ft. Z Other Distribution box (�— Dosing nk ( ) Percolation Test Results Performed by.. 7 -- (=` ` Date....,s��_C !n.7. � a - f Test Pit No. 14_1,minutes per inch Depth of Test Pit.....1.24... Depth to ground water_ WVI�2- Gr, Test Pit No. 2........ ......minut s per inch I pth f Test Pit.................... Depth to ground water.__.._........_......... - � }, ................................................ O Description of Soil ......... it. ....... ............................................... W V .--•-------••-•----------------•--------•------------------------------•----•----------------------------------------------------•-------•----•-••--------•-•------------------------------------ W VNature of Repairs or Alterations—Answer when applicable............................................................................................... -•--------------------------•--------------•-------•-------•---•---•--....--------------...........-----...-•-----------------------------------------------------------------------------•----......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE:, 5 of the State Sanitary Cod —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ed by the boa ealth. Sig d. .-= .,. ----- -------------------- ---- -- -- ------------------------ ------11- -------------------- Date Application Approved By..... .�. -• ... . ----•- . . .. ....... Date Application Disapproved for the following reasons:........................................................................................... ............_. ...............................•-•--------..........-------------------•---•-----•----•---------------------•--------•------------------•••--••--••.................................................... D to Permit No....... ................................................ Issued-- -- --•--•- Date -�-- v' C1.1 No.........." . ... FEs.............................. >:s .THE COMMONWEALTH OF MASSACHUSETTS �5 - BOARD OF HEALTH �,11 Applirtttion for Uiipnsttl Works Tontitrnrtion ramit Application is hereb made for a Permit.to Construct ( ) or Repair ( ) an Individual ewage-Disp al Syst a . ...... .. -- .Af.._\-._ ....f.............. .. K ...../ ............. ......... .. .__...y. .-.-..........-_..............-..__. Locatio Address J or t No. • ..... G.... -- ... ... .........................................................•-- ................ wner Address W � Installer Address : Type of Building/ Size Lot..........................`Sq. feet Dwelling— o. of Bedrooms...... ..................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons•_.."'S.............._._... Showers ( ) — Cafeteria ( ) QI Other fixtures ..................... ... rrtt W Desi Flow..................t��......... ons per person per day. -Total daily flow............. _ gallons. l� � G�I�€�� P P P Y � Y Q------------------- WSeptic Tank Liquid capacity...._._ Ions Length________________ Width___.__._______.. Diameter__.__..__...____ Depth____:`_--.-..__. x Disposal Trench-77 No ____________________ Width .......� -. ........ Total Length..__........ Total leaching area....................sq. ft. Seepage Pit No_______ ________ Diameter.-.-_> .�5._. Depth below i let.......... .... Total leaching area. �..sq. ft. Z Other Distribution box.( ) Dosing ttaank ) Ot /�G'AAwl r�s� �- Percolation Test Res is Performed by..�1-G 7 ...... ~ • - Date_•-/D - 7 a t-�. ,.� Test Pit No. _________minutes per inch Depth o. Test Pit.................... Depth to ground water•_______________•______- ( Test Pit No. 2... n,in*/p%,.W' chV Rr th Test Pit.................... Depth to ground water........................ --------------------------••----------------- •----------------------- ODescription of Soil-----------------------------•------••-•------...---•--.......--••-•-----------•-----------------------•------------•---•---------------------------............------•. x UW ...........................................----•-----•---=---••-•----•------•---------•-•-••--•----•--••••-•-•----------------------••--••-••-------•--•••••-----•••-••-------••----••••------...--•--- Nature of Repairs or Alterations—Answer when applicable............................................................................................... ......-•----------------------------------•---------------------...............----•---------------------------------------------------------------------------------••--------•--- Agreement: The undersigned agrees.. to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI,; �5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Slgn Hate ---- Application Approved By........ ...... ... ......................................................... / Date Application Disapproved for the following reasons---------------•-----------------------------------------------•------------------------------•••-•••--........•- ---------•-------------------•------..........--•----------------•---•--•-•--•------------••---------------•-••--•--••--•-••-•--•••----•--•--•---••-------•-•-•-•••••----------•---=•-•----•--•-•------- Date PermitNo..............................................----------- Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O,�HEALTH - : . �rr#ifirtttr of �unt�littnre �" A' THI S TO ERTIFY, That the Individual Sewage Disposal S-stem constructed ( ) or bY----------. . ,...: ............J./_�}..{.!•7f../ r -- ............../] s $ --- I7 .� ,t#I Y fr •{ C 4 ` +' / / I. 'nC tll� L, �__ J Mat........ .................................................. Yr................... - ------------------------------------------- -----1---'----•--•------------ has been installed in accordance with the provisions of TIT A) : Mate Sanitary Codj"as/dM-er�ef- the application for Disposal Works Construction Permit No........ ............................... da.ted_-----____-_-_-____---._.__-___.__-_--__-------- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ---------------------------------•------------•-•••-••----::......... Inspectory ......--.........•-•-•-•••-•••-•-••-•-•-•••••-•---...--•--.........--•....--•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OFJOIIEALTH a. 1• S" . � .OF. No........................: FEE:.._.:...._... Diapont I nni r ion "[motif Permission is 106y granted,. -- ..... er> •--- to Construc r geir t at No. _........... ----_ _ _• .................. ' ' 14- . Stre as shown on the application for Disposal works Construction Per. ' o- -_ ... -.�_ ,�,,,�►_ �............: -, ----------------------------------------•-----•--------------------_-•_-•-••_-•--. j t Board of Health DATE. ----•---- c . FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS assor s map and lot number .......................� •................� III SEPTIC SYSTEM MUST BE .. 7 _ COMPLIANCE INSTALLED IN CO NC 2 S Sew WITH ARTICLE 11 STATE + geerm�t number .......................................................... SANITARY CODE AND TOWN �pFTAEr,�y r t TOWN- OF BARN AUEE 47 Z BJBH3TADL•` i 9� OM lk. BUItDING INSPECTOR APPLICATION FOR PERMIT TO G ..................................................................................................................... TYPE OF CONSTRUCTION ...........U1 IE ....frj i;v.........C��....................................... .............................. ............�'�. '...19 7 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according-4-61�� the following information: Location ....... v.�....�i07� oS......... d .... .... ........ f� �!!!. ..................................... ProposedUse ......I..1.......t, .�....................................................................................................... .............I......................... o T ZoningDistrict ... ................................................................Fire District ........�................................................................. Nameof Owner /r � s ...........Address........................................................... .................................................................................... Name of Builder .Otvpew6e r:D o&,,Pih6,...l�":...........Address ... ®.. ?'... .....�351�/� .�.A��:...02&4,7- Name of Architect .,hl'` hj ........Address .....0.h b.e7.wj. .. l d. ..............................................?....1�.......................... .... ......... Number of Rooms .....Foundation �� ............................................................. .... .................................................................. Exterior 1 ;YTf� GLc%i �i r` %�L'S Roofing ...... d �� .. I ys ......'./................... .......5....... ........................... ;R. . ............... .. ..�....... ................... Floors ......l�-prj...W ....................................... Interior ........ .?`,f. u �'-f� ......................................................... HeatingC3. ...1t2` ?Cr ................................................Plumbing .................................................................................. Fireplace ........VGS................................................................:.Approximate Cost ............. .......... Definitive Plan Approved by Planning Board -----------____---------------19____ . Area ........" ................ .... Diagram of Lot and Building with Dimensions Fee ......... ...................... SUBJECT TO APPROVAL OF BOARD OF HEALTH