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No.....71
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
ApplirFation for Disposal Varks Tonstrudivit Prrutit
Application is hereby made for �L Permit tolConstLuct ( or Repair ( ) an Individual Sewage Disposal
System at. /V AWLA' S AAtLL < /U-J,
...........S-3Z..........2 1....J-`/1 �
---- ----------------------------------- = = -------------------------------------------
Location-Address or Lot No.
......�eJm !? ------------------------------------ ---` /'tiA.� �sL t�Q �L... EAV: .................................
Owner Address
a = .................................................................... �f> , q............
Installer Address
Type of Building Size Lot..... ---------Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a
d Other res i.
W Design Flow---I_! _l --.-gallons per person per day. Total daily flow.....��.......................gallons.
WSeptic Tank—Liquid capacityiSW-.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No...:................. Width.................... Total Length--------r---_._G/Total leaching area...................sq. ft.
Seepage Pit NO.__ �U�A /_.. Diameter._�.�°. Depth below inlet.S ... Total leaching area; _sq. ft.
z Other Distribution box � Dosing ,ank�( /�)
aPercolation Test Result Performed by. _. A ' .b..G&.../� :............. Date....--.......--.... ........._- _/.
a Test Pit No. I....___._.minutes per inch Depth of Test Pit_//..._____.___ Depth to ground water........... .�....
f= Test Pit No. 2�:. ....minutes per inch Depth of Test Pit_//_P___.._._. Depth to ground water__"- .j..
--- -------------------- ....... •--- --•--
O Description of Soil,_
c.� ?..... _.. r. l_ t.s�..... Z.3 ...........................................................................
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•-------------------------------------•-•--•--•--•-•------------•----...--------•----------------------------------•---- .........................................................
Agreement: �P�,ZH Of M9
The undersigned agrees to install the aforedescribed Individu ge Di stem in accordance with
the provisions of TITLE 5 of the State Envir enta Co e—T der�d f agrees not 7t ;lce the
system in operation until a Certificate of Com iace as e su he rd of
No.2 l
Signed ` �` '0�ro��c ..............33 Q.��=- ----------- Date
.t� /STER F.
- --. 4-
Application Approved By ----- NAU e¢..---
foApplication Disapprovedr ................. - /.-
the following reasons- ---------- ------------------------------------ -------------------------- -----------------------------------------------------
--------------------..................------------------------------------------------ ----- ------------------------------- --------------------------....................--------Dace----- --------....------
--------------------
// Dace
PermitNo- ------------ -. _1-- -.-` --_---------.--- Issued ---------------------------------------...............
a
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DOS - Q0 '";L--
13 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF 'HEALTH
TOWN OF BARNSTABLE
Appliratinn for Disposal Works Tonotrnr#inn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: /��/�l—�SiQ�� /L�[LL.� �GC1 r9Aa_/,,�DIZZ-6
---••-- = 7__......... 1• - �f ..................... ............................ ---`-•- -........................................
Location-Address or Lot No.
......12.A �_f� �, t..l! t:�::-•-------------------•--- -`��.l'(�1_f1 l t�A..�?...a-'' Cyr'T,.............................
Owner Address
a o LTa fJtiT, /> r R
........._ .. --------------------------•---------------- - r�' M �! -----------
...............•--
Installer Address
dType of Building Size Lot...!9;�:.!AL .........Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
- Ot r fixr} res t'------------------'-----------------------'----- . . --------------------------'"'
W Design Flow.............._._ �E1l�_.__gallons per person per day. Total daily flow____-�� ..._.._...._...........gallons.
04 e
W Septic Tank—Liquid capacltyll--gallon Length---------------- Width................ Diameter._______.___..-- Depth................
Disposal Trench—No..:.................. Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit NO...0&Z-F� �... Diameter... t_ Depth below inlet_:eV:2�...`�. Total leaching area;3Z sq. ft.
r Z Other Distribution box l/) Dosing ank ( )
~' Percolation Test Result Performed by.___ A4 C_.1c. - a�. --------------- Date......................................
a . _.........
4 Test Pit No. l._"__ ......minutes per inch Depth of Test Pit_�Y.!_...... Depth to ground water.."f'...Z.-�__.
4.1 Test Pit No. 2---Z----_minutes per
inch Depth of Test Pit. _�_________ Depth to ground water__7,L___z--�_ __
= ............---- ------ --------------- - -----------:.-----------
° `'� �' c--------- , S
Description l Soily.�_ �� � ! - = -
----- ..: �.s4..... c��.... -ok --------------------------------------------------------------------'------
U ,- --- P •--- -
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 Envir6�mental,Co-e—The undersigned further agrees not to place the
-F system in operation until a Certificate Of COmplince asKee! issued .y the board of health. -
Si ---- �gned -- 6 ............................................. ........................................
/ . t C / _.;,��,.r ;. - Daze— Q�/
Application Approved-By =s Dace
Application Disapproved for the following reasons: ........................................................ ...............................................................
Dace
PermitNo. ............5 /---"--l-- -.. -......---...----- Issued ......................'Dace.......................................
. 1
r
THE COMMONWEALTH OF MASSACHUSETTS
�,,_�.•-- ""P..- BOARD OF HEALTH
a
TOWN OF BARNSTABLE `
Cger#ifirax#e of &.111 liatnre
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
e
by e .��r'----------------------------------------------
Installer'
at . --.---- �l .. --------------------------------------
------------------ ----- -
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ........�1 .45.c;.......... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION�SA SFACTORY.
M
- -
. /...`DATE---------------------------------- --� --------------------- Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
!..:....C..� FEE.....,�l..�l).....
Disposal rks Tonntrnrtiun "permit
Permission is ejreby granted.------''--'--M.41_....Jv(l�!L ...................................................................................._....
to Construct (�l or Repai��} an In ividual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction Permit No..�I-'S..,e , Dated..........................................
-------------------------------------�_-o..l_.
�j
DATE..'.... ..------ � _j/ ........................
' Board of Health
FORM 36508 HOBBS&WARREN.INC..PUQLISHERS
X •-
TOWN OF BARNSTABLE . Meat
LOCATIMN ) 7-e ly SEWAGE #- ql--.���
VILLAGE A?,- 5PY A114 ASSESSOR'S MAP & LOT
w ,
INSTALLER'S NAME PHONE NO. To 4,1 AO /1"0
,SEPTIC TANK CAPACITY 15-0
' l LEACHING FACILITY:(type) lei t (size) �0 X !(f
NO. OF BEDROOMS _PRIVATE WELL OR UBLIC WATE
BUILDER O OWNER
DATE PERMIT ISSUED: ' 1
DATE COUPLIANCE ISSUED: Lai,
VARIANCE GRANTED: Yes No
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572 Cotuit Road 4/16/03
Mar,stons Mills,Mass.
026-48
1 -1500 tank.
1 -Distribution box.
1 -1000 gallon leaching pit.
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DATE: 4/16/03
PROPERTY ADDRESS:_572 Cotuit Road-� I¢oj,
Marstons Mills,Mass. 7APR003
------------------------
fi6i�lty��8A�NSTABLE
02648 bALTW DEPT.
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1500 gallon septic tank. MAP I
2 . 1 -Distribution box. PARCEL ; 00(o0rs'Z
3 . V-1000 gallon precast leaching pit. ! ^r
Based on my inspection, I certify the following conditions: -_..........
�...,�..
4 . This is a title five septic system. ( 78 Code)
5. The septic system is in proper working order at
the present time.
6 . Waste water is 61 " below the invert pipe of the pit.
SIGNATURE: ,'f -
Name:_J_P- Macomber Jr ._
Company: Jose_ph_P. Macomber-& Son , Inc .
Address: Box 66
--------------------
Centerville , Ma . 02632-0066
--------------------
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cess pool s-Leachfields
Pumped &.Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
-\ COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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i
V
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:572 Cotuit Road
Marstons Mills .Mass.
Owner's Name: Linda Letorneau
Owner's Address: Same
Date of Inspection: 4 16 0 3
Name of Inspector: (please print) Joseph P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc.
Mailing Address: Box 66
Centerville,Mass. 02632
Telephone Number: 508-775-3 38
CERTIFICATION STATEMENT
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
Needs Further Evaluation by the Local Approving Authority
Fails
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 is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 572 Cotuit Road
Marstons Mills
Owner:Linda Letorneau
Date of Inspection: 4/1 6/0 3
=,pe : Check A,B,C,D or E/ALWAYS complete all of Section D
AJO I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the
nrPsPnt time
B. System Conditionally Passes:
WO 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
,�Z 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.
ND explain:
41�) Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
)v The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
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Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 572 Cotuit Road
Marstons Mills Mass.
Owner: Linda e orneau
Date of Inspection: 4/16/03
C. Further Evaluation is Required by the Board of Health:
AConditions exist which require fw•ther 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(l)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
AM 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
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:
Ajp 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.
AJa 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.
AID The system has a septic tank and SAS and the SAS is less than 100 feet bu 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 and volatile organic compounds indicates that the well is free from pollution from that facility 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:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:Linda Letorneau
572 o ui oa
Owner: Mars tons miiis,mass.
Date of Inspection: 4 1 6 0
D. System Failure Criteria applicable to all systems:
You must indicate yes"or"no"to each of the following for all inspections:
Yes No
m
_ ackup of sewage into facility or syste 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 i_AA-axl
_ Liquid depth in ee"pml is less than 6"below invert or available volume is less than h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
�of times pumped )—./YIAu+Jy
/Any portion of the SAS,cesspool or privy is below high ground water elevation.
Y Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ e-Any
portion of a cesspool or privy is within a Zone 1 of a public well.
_ �y 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,
perfumed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.)
Xld (Yes/No)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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ 1/the system is within 400 feet of a surface drinking water supply
_ v e 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 11 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.
4
Page 5 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:572 Cotuit Road
Mars tons Mills,Mass.
Owner: Linda Letorneau
Date of Inspection: 4/1 6/0 3
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 ?
d 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,ALding 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:
Yes no/
_ _✓ 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(3)(b))
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:572 Cotui t Road
Marstons Mi11S.,Mass,
Owner: Linda Letorneau
Date of Inspection: 4, 1 6/0 3
FLOW CONDITIONS
RESIDENTIAL ,�
Number of bedrooms(design):�L Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: 4
Does residence have a garbage grinder(yes or no): ,Vd
Is laundry on a separate sewage system es or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):Al
Water meter readings, if available(last 2 years usage(gpd)): 2 0 01 =5 5, 0 0 0 ga 11 on s=1 5 0 . 6 9 GP D
Sump pump(yes or no):_Vb 2002=61 , 000gallons=1 67 . 1 3 GPD
Last date of occupancy: 01.4,-f
COMMERCIAL/INDUSTRIAL
Type of establishment: AM
Design flow(based on 310 CMR 15.203): AJA gpd
Basis of design flow(seats/persons/sgft,etc.): AM
Grease trap present(yes or no):J),4
Industrial waste holding tank present(yes or no): g
Non-sanitary waste discharged to the Title 5 system(yes or no):A
Water meter readings, if available:
Last date of occupancy/use:�$
OTHER(describe):
GENERAL INFORMATION
Pumping Records �f
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped:_gallons--How was quantity pumped determined? IVA
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
U 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)
/(Tight tank 40 Attach a copy of the DEP approval
Nd Other(describe):
Appro imate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):A_0
6
f
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 572 Cotuit Road
Marstons Mills,Mass.
Owner: Linda Letorneau
Date of Inspection: 4/1 6/0 3
BUILDING SEWER(locate on site plan)
r
Depth below grade: J�
Materials of construction: Vbcast iron r/40 PVC_other(explain): V14
Distance from private water supply well or suction line: /�"f
Comments(on condition of joints, venting,evidence of leakage,etc.):
Joints ap=Par tight -No Pyir3Pncp of 1PakagP_ThP system is
vented through the house vents.
SEPTIC TANK:Zlocate on site plan)
Depth below grade: 1�
Material of construction: +/concreteA)d metal 4I fiberglass polyethylene
,1Ather(explain) 05—
If tank is metal list age:4Z is age confirmed by a Certificate of Compliance(yes or no);, , (attach a copy of
certificate) /
Dimensions: ��
Sludge depth: A4,A _
Distance from top of sludge to bottom of outlet tee or baffle:'/(c4'
Scum thickness:/74 tt_
Distance from top of scum to top of outlet tee or baffle:/4et
Distance from bottom of scum to bottom of outlet to or baffle::
How'were dimensions determined: Z&AWO
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of-leakage,etc.):
Pump the septic tank every 2-3 years. II�let & outlet tee are
in place.The ank is structurally sound and shows no evidence
of leakage.Liquid level at the outlet invert is 51 "
GREASE TRAPiAt on site plan)
Depth below grade:M
Material of construction:4)/9 concrete meta fiberglasylpolyethyleneA44 other
(explain): AM
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: L)4
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Grease trap is not present
7
Page 8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 572 Cotuit Road
Marstr)ns Mi11s,Mass.
Owner: Linda Letorneau
Date of Inspection: 4/1 6/0 3
TIGHT or HOLDING TANK4/n&j�tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 4M
Material of construction: AM concrete metal&fiberglass 41,4 polyethylene AM other(explain):
Dimensions:
Capacity: At gallons
Design Flow: N allons/day
Alarm present(yes or no): Alh
Alarm level: AA4 Alarm in working order(yes or no):A
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX:Zof present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 'VX
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 one lateral.No evidence of solids carry
over.No evidence of leakage into or out of the box.
PUMP CHAMBER4eLK�locate on site plan)
Pumps in working order(yes or no): �(JQ
Alarms in working order(yes or no):�
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Qiim rhamhar i a nnt- =rPSPnt _
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:572 Cotuit Road
Marstons Mills,Mass.
Owner: _Linda Letorneau
Date of Inspection: 4/1 6/0 3 Zoocate
SOIL ABSORPTION SYSTEM (SAS): on site plan,excavation not required)
1 -1000 gallon precast leaching pit.
If SAS not located explain why:
Located: See page 10
T
leaching pits, number: L
/M) leaching chambers, number: Q
NO leaching galleries,number: O
/�0 leaching trenches,number, length:
/ Q leaching fields,number, dimensions: O
D overflow cesspool, number: 0 �-- C `
innovative/alternative system Type/name of technology: /� C�4 4?4e,/)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Loamy sand to medium fine sand No signs of hydraulic failure
or ponding Waste water is 61 " below the invert arc-
dry.Vegetation is normal.
CESSPOOLS(,&&(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: O
Depth—top of liquid to inlet invert:
Depth of solids layer: /J
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cesspools are not nrespnt
PRIVYA?d&(locate on site plan)
Materials of construction: Ito
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
_Privy is not prpspnt
9
Page 10 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 572 Cotuit Road
Marstons Mills Mass.
Owoer:Linda Le orneau
Date of Inspection: 1 6 ,0 3
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public.,Yater supply enters the building.
CJ
10
Page 1 1 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:572 Cotuit Road
Marstons Mills,Mass.
Owner: Linda Letorneau
Date of Inspection: 4/1 6/0 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
r
Estimated depth to ground water �d feet
e
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: NA
YESObserved site(abutting property/observation hole within 150 feet of SAS)
Ey L Checked with local Board of Health-explain: NA
=Checked with local excavators, installers-(attach documentation)
yam—Accessed USGS database-explain: http: //town.barnstable,ma.us.
You must describe how you established the high ground water elevation:
Used: Gahrety & Miller Model. 12/16/94 Ground water elevations above sea level.
Used: USGS: Observation well data. June 1992
Used: USGS: Technical Bulletin 92-000-1 Plate #2 Annual ranges of around
wAf r ions-
��T"GrO�t n
Leaching
Pit /4!�
�D s
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom i
Of the leaching pit and the adjusted groundwater table is LG�
feet.
11
y.•nrnr+rrntrs*-r— rnrmr•nssnrT.rtasnrecn::�e•*rmrl�+rrrmr. nsrti-er>'+a'�mr,ern .
1 'I'UHN OF Barnstable �_�• • � •'
WARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
.•••T••1�T••.••.•e— .IIT. .ITT. ;►f11'R.1TI1TTlR1Tf.I"RT:1—•.•1."11RT7>tl'R1r'TRITCtIq��'Ip11lA! f TnH
-TYPL OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 572 Cotuit Road Marstons Mills,Mass.
ASSESSORS MAP, BLOCK AND PARCEL # &V
OWNER' s NAME Linda Letorneau
PART D - CERTIFICATION I
NAME OF INSPECTORJoseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Inc':` '
COMPANY ADDRESS Box 66 Centerville,MaSS. 02632
Strea Town or City scat• LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
I
address and that the information reported is true , accurate , and
omplete as of the time of.-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
System PASSED
The inspection Iihich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED* \
The inspection which I have con Ucted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature
Date
ne copy of t1lis ce ification must be provided to the OWNER, the BUYER
( where applicable ) and the 330ARD OF HEAL'I'iI.
* If the inspection FAILED, the owner or " perator shall u
within one year of the date of the inspection, unless allowed dortrequiredm
otherwise as provided in 3.10 CMR 16 . 305 .
partd .doc
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