Loading...
HomeMy WebLinkAbout0062 ALTHEA DRIVE - Health TY 62,ALTHEA,DRIYE BARNSTABLE - A= 334-043 lF- A \y A k ry i M i M c� Commonwealth of Massachusetts 33L}-043 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t , 62 Althea.Drive, Cummaquid, MA {' Property Address t Donna Marie Nelson, P. O. Box 333, Cummaquid, MA Owner Owners Name / information is Cummaquid ✓ MA 02637 -- 11/12/2020 required for every page. Cityfrown 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 f"forms When �fillingng out A. Inspector Information ( 5oLf a„on the computer, Reid C. Ellis use only the tab key to move your Name of Inspector cursor-do not Ellis Brothers Const. Co. use the return Company Name key. 23 Enterprises Road, P.O. Box 59 Company Address Yarmouth port. MA 02675 Citylrown State Zip Code rnoo 508-362-6237 S121891 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 16.000); 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 main nance of on-site sewage disposal systems.After conducting this inspection I have determined that the ystem: 1. Passes 2.. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6 Inspector Ignature 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 ynder the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/W018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Althea Drive, Cummaquid, MA Property Address' Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 11/12/2020 . required for every page. City/Town 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 fo any information which indicates that any of the failure criteria described )0in 310 CMR .303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as d scribed in the"Conditional Pass"section need to be replaced or repaired. The system, upo i completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not dete fined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 yearsc 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 i 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(Expl in below): tNnsp.doc•rev.7262018 Title 5 Official Inspection Force Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 62 Althea Drive, Cummaquid, MA aw, Property Address Donna Marie Nelson Owner Owner's Name information is Yarmouth Port MA 02637 11/12/2020 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cunt.): ❑ 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 ou or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a I roken, settled or uneven distribution box. System will pass inspection if(with approval of Board o Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replac ld ❑ 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 approv I of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): Vir�d 3) Further Evaluation is Required by the B Health: ❑ Conditions exist which require further ev, luation by the Board of Health in order to determine if the system is failing to protect public hea th, safety or the environment. a. System will pass unless Board of ealth determines in accordance with 310 CMR 16.303(1)(b)that the system is not fun Aioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.72612018 Title 5 Official Inspection Forth.Subsurface Sewage Disposal System.Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �ww, 64 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 11/12/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 114 ❑ Cesspool or privy is within 50 feet of surface water ❑ Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh b. System will fail unless the Board of He Ith(and Public Water Supplier,if any) determines that the system is functioning n a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil ab orption system (SAS)and the SAS is within 100 feet of a surface water supply or tributan to a surface water supply. ❑ The system has a septic tank and SAS a id the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS a id the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS a d 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 preser ce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other faill.re criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official tnspedlon Forth:Subsurface Sewage Disposal System•Page 4 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Donna Marie Nelson, P. O. Box 333, CummaquigllpMA 02637 11/12/20 required for every 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 cesspool 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: ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. El tributary 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. ❑ An portion of a cesspool or privy is less than 100 feet but greater than 50 feet YP P 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. /V/0 lar s em the s stem must serve a facility with a 5) Large Systems: To be considered a g y y design flow of 10,000 gpd to 16,000 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 fe t 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 r itrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapp Zone II of a public water supply well t5insp.doc•rev.7/262018 Title 5 or5 at Inspection Fort Subsurface Sewage Disposal System.Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form p) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ¢� 64 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 11/12/2020 required for every page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for aft 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 NIA) ❑ 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,xcluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ Existing information. For example,a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.726/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 11/12/2020 required for every State Zip Code Date of Inspection page. City/Town D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): _ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: c . Number of current residents: Does residence have a garbage grinder? ❑ Yes [yNo Does residence have a water treatment unit? ❑ Yes /NO If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes (I No information in this report.) Laundry system inspected? El Yes :�No' Seasonaluse? ❑ Yes Water meter readings, if available(last 2 years usage(gpd)): i Detail O/7 �— �� �9 �s P� $jam %e Sump pump? ❑ Yes 9 No is Last date of occupancy: 51,AIC-Z' j N�€�9 Ode, l-�DM 5��t19r' Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 4. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments id 62 Althea Drive, Cumma u q , MA Property Address Donna Marie Nelson, P. O Box 333, CummaQuid , MA Owner Owners Name information is Cummaquid MA 02637 11/12/2020 required for every State Zip Code Date of inspection page Cityrr in D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: �4 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 syst m? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped art of the inspection? [ Yes ❑ No Was system pum p , p as If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: • Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 18 t5insp.doc rev.7Y16f2D16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 11/12/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/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 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: Were sewage odors detected when arriving at the site? ❑ Yes P/No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: a^-17, feet Comments(on condition of joints,venting,evidence of leakagg, etc.): I l f 04 f t5insp.doc•rev.7262018 Title 5 Official Inspection Fomx Subsurface Sewage Disposal System•Page 9 of 18 r-- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA `f Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 11/12/2020 required for every . page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) SP� w 6. Septic Tank(locate on site plan): ap ��/� I'9 "( ��/d / Depth below grade: feet Mat nal of construction: concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) n If tank is metal, I' t age: y 4' Is age confi ed by a Certificate of Co /riance?(attach a cop of certificate) Yes No Dimensions: >l Sludge depth: �6 7 Ji i 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 0 Distance from bottom of scum to bottom of outlet tee or baffle q How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): may . Axe rNtd t5insp.doc•rev.7/2812018 Title 5 Official Inspection Forrn:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner owners Name information is Cummaquid MA 02637 11/12/2020 required for every page. CitylTown 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 I Be or baffle Distance from bottom of scum to bottom ol outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendation , inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evic ence of leakage,etc.): 8. Tight or Holding Tank(tank must be pun ped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene 0 other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. 0. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 09/17/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float swit hes, etc.): *Attach copy of current pumping contract(r quired). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert e . � Comments(note if box is level and distribution to outlets equal, any evidenc f solids carryover, any evidence of leakage into or out of box, etc.): oc"k' /4,5. Ae�z ��k eewW Z5��'A`X � Al,-442 if �- '- A t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 11/12/2020 required for every page. City/Town 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: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: t5insp.doc•rev.7/Y8/M Title 5 Official inspection Form Subsurface Sewage Disposal System•Page 13 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02673 11/12/2020 required for every page. City/Town 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.3; • .0bnA�lwy ' o ; n 6J 12. Cesspools (cesspool must be pumped at 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 f hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fomr:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 11/12/2020 required for every page. CitY/To`nrn State Zip Code Date of Inspection D. System Information (cont.) J 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of iydraulic failure, level of ponding, condition of vegetation, etc.): t5insp doc•rev.7/2612M Title 5 Dfficial Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is • Cummaquid . MA 02637 11/12/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters A� the Iding. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately All. Ali, 33tc �3 4 WALG t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 18 Commonwealth of Massachusetts 11 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owner's Name information is Cummaquid MA 02637 11/12/2020 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: (Check Slope 1A1_M1 _ _ []r Surface water Check cellars /❑ Shallow wells Estimated depth to high ground water: ° 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 youestablished the high ground water elevation- /it - / 7 V Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7Y18/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 18 I . . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Althea Drive, Cummaquid, MA yV Property Address Donna Marie Nelson, P. O. Box 333, Cummaquid , MA Owner Owners Name information is Cummaquid MA 02673 11/12/2020 required for every State Zip Code Date of Inspection page. Cityrrown E. Report Completeness Checklist Comple all applicable sections of this form inclusive of: A. Inspector Information:Complete all fields in this section. Certification: Signed&Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3,or 5 completed as appropriate (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 I t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i TOWN OF BARNSTABLE . LOCATION ZO SEWAGE # �f/O } VILLAGES ASSESSOR'S MAP & LOT 33 -6 INSTALLER'S NAME & PHONE NO. 3 -7 7 SEPTIC TANK CAPACITY /00O 6,-1 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ` Ji CQ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No C7 . 71 ITi -Af:;s 33Y VZ No...,[pZ.- . ... Fim$.......A00........ 5-7 O THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphratiou for Uhipoii l ' orka. Tnnutrnrtiun ramit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: � n .�P .-�'` ......�T ,�f..--------------�..v---•-••-•-•---... _....-----�-U,��-----.� //----...----------...........................-- /6 /_Y5 Bloc ' ,r3ds Ca. C�NT,�,� Pr�e� ..... �...- .- ._...---••----•----- t �....... ............_ .. //-� �/ //` l���ddress...............•--•----•-• --------... -------------- --••---------------------------- ... feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder eO) aOther—Type of BuildingiWUOA_FRAm,�-O. No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ---------- ------•--- ---------- ----------------------- ---------- W Design Flow..............1`0....................gallons per per day. Total daily flow.._.......3 ®._._.... ....._...._..gallons. WSeptic Tank—Liquid ca.pacitv1XV._gallons Length. __k"_.. Width-_-� ®.`�._ Diameter.S`- -__• Depth..,-.y.... xDisposal Trench—No. .................... Width---.-----------.- Total Length......... ________ Total leaching area_.______._.__.:_.__sq. ft. Seepage Pit No.........�.......... Diameter_____ _______-------- Depth below inlet!5._�______ Total leaching area.a�J�...sq. ft. z Other Distribution box ( ) Dosing t nk as Percolation Test Result Performed by �'� -°`---•-_• - --- Date__-?.. ............................� " �.6 4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..__,O.V.d!v ..- 44 Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water......................... ... ... 0 Description of Soil...Q _�J :.. T_�._...Y'�' ....G.......... - .................................... ................ x f U ---------------•---•-------•-•--------.....----------------------------•--•--------•----•••---•-•-•---•------•--------•---•-•---------------•-=--------•....-•----------•-----------......-------------- W --------------------------------------------------------------...... •.................... ------•--- ------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ - - -----------------•----------------•-------------------------•------....---•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl has been i ed b the board health. Signed Date Application Approved By .............. ----------- ------------.----------------------------------------------------- ----- .-. -yo.-Az- Date Application Disapproved for the following reasons: --------------------- -- -- -------------------------------............----------------------------------------._.....------ -------------------------------------- -- -- ------------- -- -- -- ------------------------------- ---------------------------------------------------=------------------- ------------- ....................................- Date Permit No. ---------C� ' ".......................... Issued :-----� " ... Date V� P © THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tontrn.r#ion Prrmit Application is hereby made for a Permit to Construct ) or Repair ( ) an )Individual Sewage Disposal Sjtem%a ' /�L Tf , "�j �J/2 /VE , L' um --0."••_- - La�ti n 21 _............ .............................••••......_.-_.._.. /,5 y //-) /J -/✓C7 SS 1 Q. �f'/VT JI vorlLe? ------`===---•=-----�.//....------ �a ---------------------------------- ......._e----..... ._..._ iE� c%%�. '�wi_"ner CAddress ............................ ----------------------------------••-•-•••------star 1.4 Instailer � Address ��` � ry � OI f0 UType of Building Size Lot___________________________Sq. feet Dwelling—No. of Bedroo��nn��.._.....__::.<__Y ...._Expansion Attic ( ) Garbage Grinder (/0) � GvOGIJ ��5�i I aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfi es -------------------------------- --------------------------------------- _,_.=...------.._........---•--..._------ d /V ,3k-- -------------- W Design Flow.....................................____gallons per perso p ryday. Total dail flow..____.__ ,j .._ gallons. 1:4 Septic Tank—Liquid capacity��U...gallons Length�..�_...... Width.y__�..._.. Diameter- ..... Depth_: ........... Disposal Trench—No..................... Wid� <_.....__________ Total Length.....,a;,__..._. Total leaching area_ ..:-----------sq. ft. Seepage Pit No_____________________ Diameter......__-----_...... Depth below inlet ................ Total leaching area_.�-_6's__._.._sq. ft. z Other Distribution box ( ) Dosing nk (¢}- ~' Percolation Test Resuls� Performed by �ti �' :. v---------------------- Date ?--`��._. 6.. a � Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f=; Test Pit.,No. 2----------------minutes per inch Depth of Test Pit___-__---_-_--_-__-_ Depth to ground water-_--_-_____-____-_------ O Description of Soil.... ......-. --j, .-�-..... ..-�....: f�---...�.%LF sal Grtil V --------------------•-------------------------------------------------------------•----------------------•-----------------------------------------------------------------•---------------------------- W UNature 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 Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli ti, ,has been rued by the board f health. SignedL Dare Application Approved By .. --------------- 1 Application Disapproved for the following reasons- -------------------- --------------------------------------------------------- ---------------------------------- ---- ------------------- Dare Permit No. -. "--..-- ....-------------------------------- Issued --- '` V. ---------- re � Ly THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ger#tftrate of Compliance ' THIS IS TO CERTIFYITh t the I div dual Sewage Disposal System constructed ( X ) or Repaired ( ) W by v -�....�.../_...................._. _...__._._.._.(---"'-"---�I�YYZ_..In taller at .................................___--___.....-....______.._.....________.-.._............_.......................... 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/�... ............ dated &.r.�__A_l96�---- ....__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA�RANTE6 TH.4T THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ........... —------------------------------------------ Inspector ............. ----------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ii TOWN OF BARNSTABLE No .- .....� �11i1 Bill sal work Tons r rt_ rrntit Permission is hereby grantedr - j L I ....................................................... to Construct (X) or epair ( ) an hndivi ual Sewage Disposal System at No. j-------- 1x� yr2 -�1 ------------------------------------------------------------- ---------------------------------•---------------------------------------------------- Street as shown on the application for Disposal Works Construction Permit N�-h9----- Dated^-_may r ---------- ------------•------------------------•------------------------------------------------------------------ --------------'------- Board of Health DATE.......................................-#._...--•--------- FORM 38SOB HOBBS&WARREN.INC..PUBLISHERS I . 'rtJE516tJ �ATA i i'$Evtitst'. a� s - p�,lL +clib= t � - SEPItc TANS=3 � Iso7� �-asbP� - _ -r- - ti lXi I Co.:,GA(. W. 5lDEtIVdt.L T VF � 4 OTT F _ _ - -�-.: , L�U AA Ail U1- = ,. j=i.ay►/ �i3G� G+'�, ..off.; - _ TtoN ea )C:A, q ASS , , CfW�_`ter 4. ��y�� o• --a-- Q� -- �s . TIN r P.5W3 {I ; ZV — S�8-- - ) - -- --- - _ H' 99 4�rv. � vK � Gal. co Co ►u!1: 9"i i T'ANk r I 1 a, : j I 97; wl t : I SRd1D . WM96E �Oi 39 j _.T WE. Q 5 ' , 14 -aEv i �.OG 10 6u44 AAQUlD l3 EL7.77'. ;. tail ( �� S1 A-I-C ; 4 PLAN fLF�JCE• t ---- - PEE 1:SEdOwtJ : �lE�ZEaN- coMPc S wri'�4 Tt1 ..(5 _ I,�T ;_. t�E�tiJ 5 , T . . :��, �� `tU1RLt�( off:�I3�►JT1�3t:�. PL BIC MAP � 4 I j ' 15 (emu �15'T�vtitWr z:k\,11 �IIJ tzS rzv1LL&_ : MAI , } - PLtcQ Tr; s 1Y>G u ��lu - 1 - MAP T�4 R:L.L Al 43 . . 90 s 14. GY PETER- 8 SULLIVAN No. 29733 � y1 25Y, 14 0 10- OF Per, 12�.ao 0 .�,�.. Al>�u►ao ',�N 4 A. t� BAXTER �Db.2sOt� DOVE � a 4-1 2