HomeMy WebLinkAbout0089 TROUT BROOK ROAD - Health 89 Tout Brook Road A %
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A= 230-025
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Nov 06 2019 23:42 HP Fax page 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
89 Trout Brook Road
Property Address ft.
Estate of Mary Fratantonio
Owner Owners Name
informations (rOtUlt ✓
required for every MA 02636 11-5-19
page. CityfrOwm State Zip Coca 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,
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Important:When f
A. Inspector Information ,t
filling out forms p �/-�'�Ta�a� 0? y
on the computer, = r JA M E S u
use only the tab James D,SearS 3 g. ;rn
key to move your Name of Inspector
cursor-do not Capewide Enterprises
use the returnJ`
key. Company Name
153 Commercial Street
VQ Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
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
11-5-19
pector'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.
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'y Commonwealth of Massachusetts
Title 5 official Inspection Form
11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owners Nameinformation is Cotult
required for every MA 02635 11-5-19
page. OtylTovm 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:
The system i s a 1250 Gal. Tank D Box an
y d two pits.
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):
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Commonwealth of Massachusetts
0 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owners Name
inormation is
requiredforevery COtuit MA 02635 11-5-19
page. City/Tcwn State Zip Code Date of Inspection
C. Inspection summary (Cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection If(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 timesja 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):
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.
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R
�L\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r II
v
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owner's Name
information is required for every Cotuit _ MA 02635 11-5-19
page. CitylTowa 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
'I due to an overloaded or clogged SAS or cesspool
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
f) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owner's Name
information is
required for every Cotuit MA 02635 11-5-19
page. City(Town 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 l is less than 6"below invert or available volume is less
than '/:day flow 01-t—
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria Indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owner's Name
Information Is required for every COtUIt MA 02635 11-5-19
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 C.4 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 aH 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))
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
Properly Address
Estate of Mary Fratantonio
Owner Owners Name
information is
required for every Cotuit MA 02635 11-5-19
page. Cltyrrown 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
Description:
1250 Gal. Tank D Box and two it's. R
Number of current residents; 0
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
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)); 2017-16,000Gals
Detail:
2018- 1,000 Gal's
Sump pump?
❑ Yes ® No
Last date of occupancy: NA
Date
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
v
89 Trout Brook Road
Property Address
Estate of,Mary Fratantonio
Owner Owner's Name
information for
is Cotuit. MA 02635 11-5-19
required for every
page, GityfTown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/lndustrial 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, NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
rX 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s
y 89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owners Name
information Is
required for every Cotuit MA 02635 11-5-19
page. CityfTown State Zip Code Date of Inspection
D. System Information (cons)
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:
Around 1980 New D Box 2011 Permit #2011 -227.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 3-
- feet
r .
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.):
Pipeing is 4" PVC SCH 40.
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Commonwealth of Massachusetts
g Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F�
•V.
89 Trout Brook Road
Property Address
Estate of Mary Fratantonic,
Owner Owners Name
information is CotUit
required for everyMA 02635 11-5-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
6. Septic Tank (locate on site plan).-
Depth below grade: 22'
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: 1250 Gal. Precast H-10
Sludge depth:
1'
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle 8'
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuflt-Tape
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,):
Tank at working level.Tank at 22"below grade wloubet cover at 6". Inletbaffle, outlet tee. No sign
of leakage or over loading,
l
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owners Name
information Is
required for every Cotuit MA 02635 11-5-19
page. GityiTown State Zip Code Date of Inspection
D. System Information (cont.)
7, Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
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Commonwealth of Massachusetts
UT Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
-
Property Address
Estate of Mary Fratantonio
Owner Owner's Name
information is
required for every Cotuit MA 02635 11-5-19
page. City(rown State Zip Code Date of Inspection
D. System Information (cant.)
S. 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 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.):
D Box is 16"x16"-26"below grade w/cover at 10". Box is clean and solid w/2 line's out. No sign of
over loading or solid carry over.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owner's Name
information is required for every Cotuit MA 02635 11-5-19
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
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Commonwealth of Massachusetts
U(7z Title 5 Official Inspection Form
V�L; , -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owners Name
information is
required for every Cotuit MA 02635 11-5-19
page. CitylTown 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.):
Leaching is two 1000 Gal. Precast Pits, Pit#1 and cover at 18" below grade. Pit#2 and cover at 2'
below grade. No sign of over loading or solid carry over in pits.Both pits are dry w/stain lines at 18" off
bottom.
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.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owner's Name
information is required for every Cotuit MA D2635 11-5-19
page. City/Town 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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owner's Name
required for
is every Cotuit
required forev MA 02635 11-5-19
page. Cfty/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch In the area below
❑ drawing attached separately
13
13'1=
;L
.5' 06.E: 30"
A- - L11
3A�
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Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owner's Name
information is
equired for every CotUit MA 02635 11-5-19
page. City/Town State Zip Code
Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'
feet
Please indicate all methods used to determine the high ground water elevation:
0 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: j
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Auger Hole 12'no G.W.. Bottom of pit#2-8' below grade. Bottom of Pit#2-4'above Auger Hole
�i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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Commonwealth of Massachusetts
p
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Trout Brook Road
Property Address
Estate of Mary Fratantonio
Owner Owner's Nance
information is
required for every Cotuit MA 02635 11-5-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary: -
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
�o o�
No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Imng out forms
A. General Information
fillip out fortes `auunnunur�i
on the computer, ��``°tGP�j...F..
use only the tab 1. Inspector: �����' •••9cti
key to move your So: • G
se �A �` _
cursor-do not JAMES
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James D.Sears
use the return -- S IF R S �
Name of Inspector ca
key. CapewideEnterprises,LLC
Company Name a .. .... -C
153 Commercial St. °/////51 iN SP"- \\``
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true accurate and complete a f the i
p p s o e time of the inspection. The Inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
9-16-13
spector'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 is a shared system or
has a design flow of 10 000 d rgreater,g gp o the inspector and the system owner shalt 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•3/13 Title 5 Olfldal 1 n orm:SubsuAaoe Sewage Disposal System•Page 1 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� 89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owners Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cunt.)
❑ 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-3113 Tide 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
"f 89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityrrown State Zip Code Date of inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
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 essoped is less than 6"below invert or available volume is less
than %day flow i°iTs
t5ins•W3 Title 5 Official tnspection 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
�< 89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
Yes No
Required pumping more than 4 times in the last year NOT due to clogged or
E] ® obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Cl ® 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•3113 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
89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® 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): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owners Name
information is required for every Cotuit MA 02635 9-16-13
page. City/rown state Zip Code Date of Inspection
D. System Information
Description:
The system is a 1250 Gal.Tank D Box and two pits.
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2011-27,000Gais
g ( y g (gPd))' 2012-26,000GaI s
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: PresentDate
Commerciallindustrial 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•3113 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
"< 89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is Cotuit MA 02635 9-16-13
required for 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: 7-7-11
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/Altemative 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 b system operator under contract
Pe Y Y Y Pe
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pap 8 of 17
f
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Around 1980 New D Box 2011 Permit # 2011 -227
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3'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.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 22"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:
1250 Gal. Precast
Sludge depth:
1"
t5ins•3/13 Title 5 teal 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
J�< 89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-TapeSludge 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.):
Tank at working level. Tank at 22"below grade w/outlet cover at 6". Inlet baffle, outlet tee. No
sign of leakage or over loading.
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-3113 Title 5 Olfictal Inspection Form:Supsurtaee Sewage Disposal System•Page 10 of 17
14 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposals System Form-Not for Voluntary Assessments
° 89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner owner's Name
information is required for every Cotuit MA 02635 9-16-13
page.e. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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.W 3 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
"t 89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
D Box is 16"x16"-26"below grade w/cover at 10". Box is clean and solid w/2 line's out. No sign
of over loading or solid cant'over.
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•31113 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
"t 89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ 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.):
Leaching is two 1000 Gal, Precast Pits. Pit#1 and cover at 18"below grade w/6"water. Pit#2
and cover at 2' below grade w/8"water. No sign of overloading or solid carry over in pits.
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
I
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 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
89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owner's Name
information is required for every Cotuit MA 02635 9-16-13
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
a / - y,
l9.3 = 3 R FA 2
/3 L3= 3 v' '�
,g-jl-3;
/3 -5= 3 0
o
f
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner Owners Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells Aj®
Estimated depth torigh ground water. 12'
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:
Auger Hole 12' No G.W.. Bottom of pit#2-8'below grade. Bottom of Pit#2-4'above Auger Hole.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
ugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Mike Vanetten
Owner owner's Name
information is required for every Cotuit MA 02635 9-16-13
page. Cityrrown 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
t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
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 the I
computer,use 1. Inspector: 3�
only the tab key
to move your Sean M. Jones
cursor-do not
use the return Name of Inspector
key. Capewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
Cityrrown State Zip Code
(508)477-8877 S14522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 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
7/7/2011
Inspector's Signature Date --a
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 syslem oo
has a design flow of 10,000 gpd or greater, the inspector and the system ownet-A)hall subinij•the '
report to the appropriate regional office of the DEP. The original should be seaEto the system owner
and copies sent to the buyer, if applicable, and the approving authority.
7-0
I
****This report only describes conditions at the time of inspection and under the conditibtws ofAe
at that time. This inspection does not address how the system will perform 11h the futare un r
the same or different conditions of use. w
�3
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis osal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection complete Summary: Check A,B,C,D or E/always all of Section D
Y
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:
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):
I
t5ins•09/08 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
wM •''r 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
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):
1)The sewer line running from the septic tank oulet to the distribution box has settled causing water to
remain in the pipe 2) The distribution box has major rotting at the water line allowing roots to enter.
Box needs to be replaced.
❑ 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 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
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:
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 1/2 day flow
t5ins•09/08 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
89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
every page. City/rown 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— IW PA) 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 17
L ^ -
Commonwealth-of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;w 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
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?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® El available
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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 gpd
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
F W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
every page. City/Town 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? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): yes
Detail:
2009= 32,000 total = 88 gpd 2010=38,000= 104 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 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
°M 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
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: 1250
gallons
How was quantity pumped determined? Size of tank
Reason for pumping: Customer request/routine maintenance
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 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
°M 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Original system installed 1975
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 2feet
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.):
Joints ok, no leakage, vented through roof
Septic Tank (locate on site plan):
Depth below grade: 1.3
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: 1250 gallons
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotult Ma 02635 7/7/2011
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
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
i liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank was cleaned as part of the inspection. Inlet and outlet baffles intact and in good condition.
Tank was structurally sound and not leaking. Water level prior to pumping was into outlet pipe, this
high water level was caused by the pipe settling, the pipe from tank to d-box needs to be replaced.
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•09/08 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
•'' 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
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
15ins•09/08 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
�M 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
every page. CitylTown 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.):
Distribution box has major rotting at the water line, needs to be replaced.
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 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°w 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2x1000 gal
❑ leaching chambers number:
❑ 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 time of inspection, leach pit (#4 on as-built) had 6" of standing water and a visible stain line approx
6" higher indicating that the water level in this pit has never been more than 1'from bottom. Leach pit
(#5 on as-built) was located but not excavated.
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 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
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 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
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
(LC-P L O) HouS
lolz
"T
SLY
TAr4 K
,q-1 20
g-1 : i9
A.Z Z5
I3 Z Z96
D-go,c
(,eAC t P ITS
3� d"
g__Y2 3i
A-5- 3`i 6"
s. y 7`
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotult Ma 02635 7/7/2011
every page. Cityfrown 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: 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:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour maps.
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 17
}
f t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GIN 89 Trout Brook Rd.
Property Address
Michael Van Etten
Owner Owner's Name
information is required for Cotuit Ma 02635 7/7/2011
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
� I
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. ao Fee
/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: v
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
AppItrattou for Xkgogal *Vmem Construction Vermit
Application for a Permit to Construct( ) Repair IN Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No.Vq rp jr &0 ok ✓L, Owner's Name,Address,and Tel.No. Ml i-"4 941"G H—leo
C,3 t-Z T Irg 2,:)
Assessor's Map/Parcel d 2). 0-73 Ge,4__'r
Installer's Name,Address,and Tel.No. (f Ltd i-�p Gh•T &j ej Designer's Name,Address and Tel.No. /7/
L 5(,dwrne.ulgL S'r
Type of Building: 4—
Dwelling No.of Bedrooms Lot Size 7,2,Doc) — sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 2
Design Flow(min.required) `J 3 gpd Design flow provided 3 / gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
c
Nature of Repairs or Alterations(Answer when applicable) fJ k,4<,2, ,�t s}��!` +7 L'r 13 O<
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date 7, ( Z— 20 l
Application Approved by Date ^1 '— oZa
Application Disapproved by: Date
for the following reasons
Permit No. got Date Issued
No. 0 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
pprication for W5pogar *pgtem Congtruction Vermit 1
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No.sq F(OJT 1-�roc)k ✓L1� Owner's Name,Address,and Tel.No. ^444
C o t-;s SC/ r/o,r,3.��c 2
Assessor's Map/Parcel b 2 Z 0-7 j.,:r
,,,11
Installer's Name,Address,and Tel.No. Cq�,*wi�t0 f:� � Designer's Name,Address and Tel.No. Alql
L177- F& 7? "-3c----w' sT'
p2`YS
Type of Building: t-
Dwelling No.of Bedrooms Lot Size ?�Zz DOO sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( ) N
' Other Fixtures ?,
o Design Flow(min.required) 330 gpd Design flow provided 3 / gpd
' Plan Date Number of sheets Revision Date
Title ,
Size of Septic Tank Type of S.A.S. 1
Description of Soil -
Nature of Repairs or Alterations(Answer when applicable) 73,o<
Date last inspected:
Agreement.:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date ZO I 1
Application Approved by Date
Application Disapproved by: Date
- for the following reasons
Permit No. d�0 /" yrz Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired K—) Upgraded ( )
Abandoned )by_ _/ j�,,�, C-k4, DR) S L cc
at 0 //2"rj3o ,, has been constructed in accordance ��77
with the provisions of Title 5 and the for Disposal System Construction Permit No. 01/- d`2 7 dated
Installer AV1 MCP 644 ,4 r!j LL,(_,. Designer G1 e
#bedrooms 3 Approved design flow j" gpd
The issuance of this permit shall n rbVcon ued as a guarantee that the system ill , esigned.
Date /� Inspector ` 7
tl
No. .rQLo � _71- --- ---------- --- — -- --�=t— --- �.� � �—_ -=Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS
Digogal *pgtem construction vermtt
Permission is hereby granted to Construct ( ) Repair (A) Upgrade ( ) Abandon ( )
System located at �c/ / /d 7 A-
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of th'.sPm
Date Approved by V,�
LOCATION SEWAGE PERMIT UO.
-
VILLAGE - - -
INSTALLERS I &L AE ADDRESS
BUILDER 5 Al &V AF- ADDRESS
DWTE PERMTT
DN.TE COMPLMMCE ISSUED : � 7�
�C..
�\
`� mw
�5� !
1
S \ ..¢ J
�:
� �� � E,
� � t 1
� �
� 91 a �!
�s
, �
f
F�a.
No..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... ........ . . . .. _.. ----OF..........................................................................................
Apphration -for R_gpoiittl Work,6 C on5trurttott Prruid
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location_Add r s or Lot No.
e.Y......`�
Own �''` 2. Address
nstaller s- Address
Q Type of Building ".'Size Lot----------------------------Sq. feet
U Dwelling o. of Bedrooms_._.�-__--_-•______________ Expansion Attic ((� Garbage Grinder ( )
aOther—Type of Building ---•----------------=------- No. of persons----------------------------- Showers ( ) — Cafeteria ( )
a' Other y�fixtures ------------------------------ --
W Design Flow.....a:�--t)............................gallons per person per day. Total daily flow-__-_d4/4?.0----------------------....gallons.
R;W Septic Tctnk 4-Liquid capacity/qV�gallons Length................ Width................ Diameter----- ---------- Depth----------------
x Disposal Trench—No. .................... Vk ith._._....._.._____._. Total Length.................... Total leaching area.............-------sq. tt.
Seepage Pit No.____`.....--...___ Diameter �.? '�____ Depth below inlet.................... Total eachiug area---------------.._sq. ft.
Z Other Distribution box ( ) Dosing to ( ) A t�.
.—_� srl�_�'& � Date
�� 7S�
'-' Percolation Test Results Performed by --?V .X 1____'. ... .1 - ....... .l -- ---- -------__--_--_.-.-.
,al Test Pit No. 1_______________minutes per inch Depth of Test Pit-------------------- Depth to ground water.--._---.-----.--.-.___.
(� Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth to ground water...........--_.--__-_---
i�. `
D ------ ----I�-' x✓m+�
escri tion of Soil . ----
.. Y
,E. ,___ �
a �
vn�lg-
.$�f
Gad M-------- ------ ` ---------••-- --------------
U Nature of Repairs or Alterations—Answer when ap licable..---------------------------------------------------------•._-._.-------.------_--.-......._...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance Abn • ed by the b r of health.
Sin -------------- ----------•-•-•--•---•--•--•-----------------------.
D e
___
Application Approved By--- Y----------- Dat
Application Disapproved for the following reasons:----------- - ---- ---------------------------------------------------------------------------.-_-
..••••-•••••-•--•••••••••-•••---••----••-••------•--•---------••••--......•••••••-••••••-•-••...-•-•••-------------------------------------------------------------- .
-----------------------------------
Permit No. Issued. `= `Z -� ate
-•- .......
Date
t
No.?S..__ .. FEs. .......
THE COMMONWEALTH OF MtASSACHUSETTS
BOARD OF HEALTH
_...... .. ---------OF...................................... .................... . ........
Applira#iiial .for Uii niittl Works C otui#rur#tlan Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:Or
!«�
t
Location Add s or t No
q� �p.'Own Address
I /0..................................... ..................................................................................................
nstaller Address
UType of Building Size Lot............................Sq. feet
Dwelling- o. of Bedrooms._-. ----------------------------------Expansion Attic Loo< Garbage Grinder ( )
Other—Type T e of Building No. of ersons_.:_________•__-__-__--__ 'Showers —
� YP g ---------------------------- P .• ( ) Cafeteria ( )
d Other 6xtures - ------------------- ----------------------
W Design Flow..... ................................gallons per persorf',per day. Total daily flow.....� ---()---------------.-----------gallons.
P4 Septic "Tank)--Liquid capacity/.2rC)gallons Length_____________'__. Width_____..._------- Diameter_.---- -------- Depth__._.____._----
xDisposal Trench—No..................... Width__-.._____________.. Total'Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No.....`, ._______ DiameterB ___. Depth begw4n let............._...... Total eaching area------------------ ft.
z Other Distribution box ( ) Dosing talk,( ) 0 . 6 ZJ e V V*4
Percolation Test Results Performed Date...
Test Pit No. I.....•..........minutes per inch Depth of aTest Pit..................... Depth to ground, water.._.___..____.____._:.. 1
f14 Test Pit No. 2-----------------minutes per inch Depth of Test Pit----:................ Depth to ground water----------...............
tY+ - • --• --- . ...
04,z--- - r--- --- ----
,
D Description of Soil__..._____ _""__40_____
------ •--•-
- '- --- -
w -- -�•
U Nature of Repairs or Alterations—Answer when ap licable..____________------------------------------------------------------------------------------
-------------- ____
•,�. r .. - - --... --------------------------
Agreement: -The undersigned agrees to install the aforedescribed Individuaf Sewage Disposal System in accordance with
the provisions of Article XI of'the State Sanitary Code—The undersigned further agrees not to place 'the system in
operation until a Certificate of Compliance has n 's ued by the r of health. `.
S ne
Application Approved BY---s. r +�+ to ?
Dat�
Application Disapproved for the following reasons_ ._______._............___..._.._...
------------------------------------------------------------•-------------------'-••-
Date
PermitNo......................................................... Issued........................................................
Date
.— THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
.. ............OF...... ..... ... ................................
::....
1USrr#ifira#r of TiMpliatta
T�y�Sf IS TO CERTIFY, Th the Individual Sewage Disposal System constructed ( or Repaired ( )
Y Yf rr
b �.- ------- �' ff
n alter 1at //( ---'------
has been installed in accordance with the provisions of Ar ' ttary Code s descri ed irkapplication for Disposal Works Construction Permit No_ _________ __ dated
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON RUED AS A GUARANTEE THAT THE
SYSTEM Vtl L FUNCTION SATISFACTORY.
DATE ------------------`----��-----------------------------------
THE Inspector
®!�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALT
' #K �1............OF....... .��.... .....:...-•----.
X.0---•-•..._••--.'•--•... FEE./....-----
Permission'is eb ranted___._____ _<.........__
Y g � �. (-------- ----------•---------------•--...... _----- •-..----
to Const t ) or Rep - ( ) an - nd' idual S ag Di p s m
at N oGt" y9� -��lW i� t�.�� ...
ree
as shown'on the.application for Disposal Works Construction it N _.. Dated_.___'2� ,� ........
- - - - . .................
�J,� _
// � a Health
of.
DATE. - -- =--------------------------•- A
FORM 1255 HOBBS-& WARREN.. INC., PUBLISHERS' "'
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