HomeMy WebLinkAbout0120 COACH LANE - Health (2) 120 COACH LANE,BARNSTABLE
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Commonwealth of Massachusetts oq 98-08v
Title 5 Official Inspection Form
�M1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
120 Coach Lane `
Property Address
Rosalie Dowd + ,�
Owner Owner's Name
information is required for every Barnstable y Ma 02630 4/15/2021
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.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
+� Company Address
Centerville Ma 02632
Cityrrown State Zip Code
774-248-4850 smjonestitle5@gmail.com, S14522
sean@smjonestitle5.com 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. ❑ Need's Further Evaluation by the Local Approving Authority
4. ❑ Fails
4/15/2021
inspectors Signa re Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 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:
The property located at 120 Coach Ln Barnstable is served by a Title V septic system consisting of a
1000 gallon septic tank, distribution box and 2 precast leaching chambers. Although the system was
found to be in proper working condition at the time of inspection this report does not guarantee future
performance under similar or increased usage.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (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):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Cityfrown 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 '/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.
❑ ® 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 .
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
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 all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. City/Town 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 gpd
Description:
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 ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
M
h
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
system repaired 2018 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
Joints in good condition, no leakage, vented through roof.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. 120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 1
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:
1000 gallons
Sludge depth:
5"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Opened covers and took
measurements
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 needs to be cleaned now and again every 2-3 years for proper maintenance. Tank has some
root growth inside that will need to be removed. Water level was even with outlet, tank was not
leaking and was structurally sound.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is Barnstable Ma 02630 4/15/2021
required for every
page. City/Town 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
c Commonwealth of Massachusetts
�d ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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 was video inspected and found in good condition with no rot. Water level was even
with outlet invert.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
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: 2x500 gals
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching facility was video inspected and found dry with no signs of past overloading. Recommend
installing risers for future inspection.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c � Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,r 120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is Barnstable Ma 02630 4/15/2021
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. City/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
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(3y S-(
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 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:
Groundwater was established by accessing town of Barnstable groundwater contour maps
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Lane
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 4/15/2021
page. Cityffown 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
I KME r
Town of Barnstable Barnstable
AFAmedcaNy
Inspectional Services l
� HAItNSTABI.E. �
9� " . ,�� Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL#7015 1730 0001 4987 9385
November 21, 2018
DOWD, ROSALIE A TR
120 COACH LANE
BARNSTABLE, MA 02630
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 120 Coach Lane, Barnstable, MA was inspected on
11/16/2018 by Michael DiBuono, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS or cesspool.
You are ordered to repair or replace the septic system within one (1)year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action. .;
PER ORDER OF THE BOARD OF HEALTH
J
s cKean. R.S., �\
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\120 Coach Lane Barnstable.doc
f ,
Town of Barnstable
9� ' ABLE,a Regulatory Services Department
rfD MA'l
Public Health Division
200 Main Street,Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool "
ONE (1) YEAR DEADLINE CRITERIA
0-I'Latic liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single-Cesspool '
❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline: ti
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts a9g-OS�
-, Title 5 Official Inspection Form
�a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Coach Ln :
Property Address
Rosalie Dowd _ '
Owner Owner's Name
information is
required for every Barnstable ✓ Ma 02630 11/16/18 0
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 4"'
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer,
use only the tab Michael.DiBuono
key to move your Name of Inspector
cursor-do not DiBuono Sewer And Drain
use the return Company Name
key. '
35 Content Lane
Company Address
Cotuit Ma 02635
Cityrrown State Zip Code
508-364-9587 S113522 .
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); I 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
I
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
11/19/18
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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner'and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
,gp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
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 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:
System contains a 1000 Gallon septic tank as well as a 1000 gallon leach pit
Pit is full to the top.
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):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Ln
u
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settle_d 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):
3) Further Evaluation is Required by the Board of Health:'
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is Barnstable Ma 02630 11/16/18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
i
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
® El Backup
SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '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.
❑ ® 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
l0 Title 5 Official Inspection Form
w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is
required
uired for every Barnstable Ma 02630 11/16/18
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
� ^ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
page. City/Town 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:
Number of current residents: 1
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 188 Gpd
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
I
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
(/pia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4"
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Pumped in 1995
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Ln
u
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate a e f II m g o a components, date installed (if known) and source of information:
Original to home
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5feet
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.):
System is vented at the roof line
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
,A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
30"
How were dimensions determined? Tape Measure
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 should be pumped at time of new install
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4�
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
El 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
t5insp.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
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
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 switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
l5insp.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
120 Coach Ln
' V
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
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: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
required for
is every
Barnstable
required Ma 02630 11/16/18
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.):
completely failed
p Y
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.):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
g Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Ln
�V
Property Address
Rosalie Dowd
Owner Owner's Name
information
equir for
is every
Barnstable
required for eve Ma 02630 11/16/18
page. Citylrown 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
11/.19/2018 Assessing As-Built Cards
TO OF BARNSTABLE a
LOCATION n SEWAGE N
VILLAG �. SESSO ' MAP&L
� sNAME&PHONE NO. t1up,
SEPTIC TANK CAPACITY G
LEACHING FACILPIY:(type) C/ Isjye) Q
NO.OF BEDR
BUILDER R OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility c Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 2W feet of leaching facility) �� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 t of 1 c ' g /�/ Feet
Furnished by,,�4 -z,—VC.
s�
291
o'
.. ' Commonwealth of Massachusetts
Title 5 Official Inspection Form
F' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Ln
V
Property Address
Rosalie Dowd
Owner Owner's Name
information is required for every Barnstable Ma 02630 11/16/18
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 round water: 31'
p g g 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:
TBD at time of perc
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Coach Ln
Property Address
Rosalie Dowd
Owner Owner's Name
isrequired for every
Barnstable
Ma 02630 11/16/18
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OF BARNSTABLE
LOCATION 26 C®ci C LAI SEWAGE#
VILLAGE &rA<$f �'� ASSESSOR'S MAP&PARCELS 6��
INSTALLER'S NAME&PHONE NO. 0'Ile"7 c� �P-�• � /�;#.^-
SEPTIC TANK CAPACITY
LEACHING FACILITY: e 5T--,)D 6-4/161iK
NO.OF BEDROOMS
OWNER
PERMIT DATE: 12 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
rve� �
FURNISHED BY � �E� ��✓�,
? s3 �N
f✓,�Lc u
1 0-
Z cj
3 �
t
N9,
S Fee "
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
9pplitation for bisposal 6pstrm Construction 3pPrmit
Application for Permit to nstruct( ) Repair( "Upgrade(. ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot 2�d � cd,,4A Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel tj Q,-o1 G �� { ®SCE i(� (,clp� 12 b �O��1ri L✓v
Installller's Name,Address, el.No_'09-30 PT. f7 Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 26 gpd Design flow provided �'� gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. ,)Ov
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code=4 not to plac a system in operation until a Certificate of
Compliance has been issued by this Boar e t
Signe Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 1 �' Date Issued p
� N
r
N �_ M Fee
o.
THE COMMONWEALTy OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOMrO 5bARNSTABLE, MASSACHUSETTS Yes
2pplication for MispoBal .6pstem Construction Permit
Application for a Permit to Construct( ) Repair( 1"Upgrade( ) Abandon( ) D Complete System ❑Individual Components
Location Address or Lot N . 2 �a, 1 C6�C� 1-✓' Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel ^ �b { �bSCc i(° (,�lp� 40 coe c/, 1-✓u
Installer's Name,Addre s`anT" el.No./3F 70 rjs'J'7 Designer's Name,Address,and Tel.No. j
Type of Building: 35
Dwelling No.of Bedrooms. Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) _76 gpd Design flow provided �y�•� gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. Z SOU 4�J4& ��I.t AoiIdX' 54-4"e
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
fDate gist inspected:
Agreement:
3 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�e system in operation until a Certificate of
Compliance has been issued by this Board—of HeaUh.
j r
Signeff Date
r.
Application Approved by ' Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
p Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(j/� Upgraded( )
Abandoned( )by ��, j.c J (v--
at 120 C46 OL L f f,j 4 ct n S 1��� Q has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NQ9I� d1ted ICA I g`
Installer QXS&O"J fO,, y 0.k ���j v` Designer
" #bedrooms Approved design flow �� god
The issuance of this permit shall not be construed as a /uarantee that the systdm will functi asi ed.
Date Inspector.._
- :- -------- --------------
No. --"Lj & Fee o c
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposaf *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(l/� Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
r--
Provided:Construction must be completed within three years of the date of this pe, it.
Date �r Approved by\�
Town ®f Barnstable
pF IH'E:rp,�,
Regulatory Services
BARN BL;E,
Richard V. Scali, Interim Director
• SI'A �.
y W.L53.
Public Health Division
AlEUMArA rhonlas McKean,Director
200 again Street,Hyannis, MA 02601
Office: 508-862-4644
Fax:
` Installer&Designer Certification Foam
Date: IZ.j Z7 ( t6 Sewage Permit#
Assessor's MaptParcel 2,9 T—G YT
PG�e� i"1cC�+ems
Desi ner:
� -►= r—, n� tJt�"L.�dS 1►i Installer: L
Address: 1 Z VJ, Crzsss7P Id P�-1_ Address:
On t�Vc?v'tlJ .� •`teas issued a permit to install a
(date) (installer)
septic system at 1'Z4 (""a L%C h L", based on a design drawn b
(addre s) -- € )r
Cn ,, ,r�..,l�t� dated
*signer)
I certify that the Septic system referenced.above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed. with major changes
greater than 10' lateral relocation of the SAS or ally vertical relocation of any component
of the septic: system) but in accordance with State & Focal Regulations. P.1an revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
1 certify that the syste referenced above was constructed in with the terms
of the RA.approv• to applic
nstalfer's Si CVit(1 Signature)
"�. ty0.35108
RFOISSE� , '
ti
(Designer's Signature). -._ (Aftix Designee ere)
f'1 EAS> RETURN TO BAR\TS7':ll3:LI; PUBLIC HEAI:TII l)i1'ISIOW-FRI-I
` I?-R'I'1PI'CATE
OF COIANCL++' «'I:[,L OT B}? ISSUCD UNTIL B01'}I T1aI A I3UTLT C.1R1) !1RC ftECLI��LD Bar TFIL BAF2NSTABLE PUBLIC I BIVISIOti
1�}TANK YOUR
Q:1Scptic`.Desi,ncr Certification Form Rev 3-14-13.doe
Engineers note:This certification is limited to an as-built inspeclicn.of system components as installed prior to backfill.The
engineer did not supervise construction of the system. =installer assumes'responsibiNy for all materials,workmanship,bacldillirg
to specified grades with proper ccmpastion and setting riserstcovers as shown on the design plan.
TTl-)e—
OF BARNSTABLE c
LOCATION SEWAGE#
VdLAGL rM V46L SSESSO ' MAP&LO
NAME&PHONE NO.
SEPTIC TANK CAPACITY MOO D G
LEACHING FACE LrrY: (type) �� (size) S'
NO.OF BEDR 0
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) /1 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 t of le 'ng facili J`� / V Feet
Furnished by O CJ D`� -l��C. �11`lf6 .
'Ulf ' 1
3g
BORTOLOTTI CONSTRUCTION, INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Prop LO
Date of Inspec Map arcs O
. ��ST wn
PART A - CHECKLIST
CHECK IF THE FOLLOWING HAVE BEEN DONE:
PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH.
NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO
THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.
AS-BUILT PLANS.HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A.
THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP.
/
v 'THE SITE WAS INSPECTED,FOR SIGNS OF BREAKOUT.
ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE,
THE SEPTIC-TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,
DEPTH OF.SCUM,
!/fHE SIZE AND LOCATION.OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED"
ON EXISTING INFORMATION OR
APPROXIMATED BY NON-INTRUSIVE METHODS.
E FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANQg F SSDS.
PART B — SYSTEM INFORMATION -
s ..:-.. FLOW CONDITIONS
RESIDENTIAL ;
No of Bedrooms . No of Current Residents Q Garbage Grinder
SLaundry Connected to System Seasonal Use
NON RESIDENTIAL
Calculated flow
WATER METER READINGS,IF AVAILABLE:
I
GALLONS
ping Records an Sourc of Information:
ell
y G �
` f SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED= GALS
Reason for Pumpingu
TYPE OF SYSTEM ��*
�''« Septictank%dlstnbuUon box/soil absorption system -
Sing_la Cesspool ° Overflow Cesspool Privy
Shared system rf yes,;attac us inspection rec rd if a
Othe,�r,,(explain)` � t
MX11ate aBeiot a1f components Date installed,If known. Source of Information.
14
jai a h
�r } `SEWAGE ODORS DETECTED.WHEN ARRIVING AT THE SITE?
4
gg 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SEPTIC
Depth below grade: Dimensions69: i 1:6--
Material of construction: oncrets Metal FRP Other}
Sludge Depth // Distance from top of sludge to bottom of outlet tee or baffle
33
Scum Thickness Distance from Top of Scum to top ofoutlet tee,or baffle
Distance from bottom of.Scum to bottom of outlet tee or baffle
c % aso�G C� LaiL/10v�
DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:
PUMPCHAMBER: Pumps in working order?
Comments:
SOIL ABSORPTION SYSTEM SAS
IF NOT PRESENT,EXPLAIN:
TYPE: Azo
Comma _
CESSPOOLS: Number and configuration
Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
indication of groundwater inflow(cesspool must be pumped)
Comments:
PRIVY:
Materials of construction
Dimensions Depth of solids
Comments:
P
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL WELLS WITHIN 100'
i
c OP7
may,
a .
z
DEPTH DEPTH TO GROUNDWATER
METHOD OF DETEiMINATION OR APPROXIMATION:
,
i+tut„„'7 P ^.FFY'i`jl.i. ` •Y 1• ..
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C FAILURE CRITERIA
(Indfs Y-yes N—no ND—not determined.Describe basis of determination.H"not determined",explain why not)
Backupka of Sewage into Facility?
Al Discharge or ponding of effluent to the surface of the ground or surface waters?.
Static liquid level in the districution box above outlet invert?
Liquid depth in cesspool, 6°below invert or available volume, 1/2 day flow?
Required pumping 4 times or more in the last year? Number of times pumped
Septic:6Ak is•metal?cracked?structurally unsound?substantial infiltration?substantial exfiRration?
tank failure imminent?
y Is any portion of the SAS,cesspool or privy,below the high groundwater elevation?
Within 50 feet of a surface water?
Within 100 feet of a surface water supply or tributary to a surface water supply?
/ Within a Zone I of a public well?
/V Within 50 feet of a private water supply well?
/V Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)?
Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen.
PART D — CERTIFICATION
INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS
COMPANY. BORTOLOTTI CONSTRUCTION INC. MA 02648 (508)771-9399
CERTIFICATION STATEMENT
I CERTIFY THAT 1 HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS 11 ADDRESS AND THAT THE INFORMATION
REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
RECOMMENDATION 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:.
V
I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC
HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED AREAS
STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM.
I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS
FORM.
INSPECTOR'S SIGNATURE;
Of
DATE:
ORIGINAL TO SYSTEM OWNER,COPIES.BUYER.(if applicable),APPROVING AUTHORITY
r<
u
t
',f
cot 9'�4
at � "'-.t ,rsK,a �•+`1.4 ar�t �k dF �'. �1s l:R N 4`; '-'�TE59',�r J:`�� 't 'k'h, Fa +n, rt t �'r r r' � 'l, 1'kf� _.''3 si. -.t..!
THE COMMONWEALTH OF MASSACHUSETTS
A BOARD HEA TH g-Ae-
. .. ...OF........... GrJ....... . --------------G..
2
Apphratiun -for Uiiplaiitt1 Norkii Towitrurtion Vrrmi$
A plication is hereby made for a Permit to Construct ( / or Repair ) an Individual Sewage Disposal
Sys at
Location. ress or Lot No.
W ne
... . ...............................t Address
CQ Installer Address �,
U Type of Building Size Lot_:.t om_. Y_Sd,_feet
Dwelling No. of Bedrooms..___--__--- _-_-.Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons..--_.----_--._-__-_--___.-_ Showers ( ) — Cafeteria (�
a Other fixtur s ---- ----------
d
W Design Flow-�--------------- �........_ allons per person per day. Total daily flow......_...�...___..__.___.__.._........_....gallons.
WSeptic Tank—Liquid capacity allons Length---------------- Width.____... ._._.. Diameter__.---_-..._-_ Depth.__-.--__-------
x Disposal Trench—N _ ____________________ Widtli____._____ ___ ota __-_. Total leaching area--------------------sq. ft.
Seepage Pit No....... . ......... Diameter.]&_._ plomin1'e*t __..._..... Total leaching area..____.-.-_.-__--sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..................................................................__---- Date.............-----------------------_-
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit:.-__-______.._--__- Depth to ground water_..-_-----_-.--.-..-___.
44 Test Pit No. 2................minutes per inch Depth of Test Pi ._______--_•________ Depth to ground water-_.--.-_--_---.---_-_-.
Q+' f - -- ---------- - - ---'--.
Description of Soil--------- --------------_- -.// - q-:---- P - -
x
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 Article NI of the State Sanitary Code-The undersi d further agrees o place the system in
operation until a Certificate of Compliance has been,,.-issued by t b d of healt
. --'-• --- ............... .....................................
Date
Application Approved By- _._.-• --- • •---• •--• '• --z ...
./7�.._..
- -- - - - -• --• -•- •-•-••-•------- ---�- -' - Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------•--
------------------------------------ - -- - ------------------------------------
2 Date
PermitNo--------------_-_---................................. Issued:.... /..................
Data
P'
r
s-
7
I .
No.............. Fps.....::�...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r .
Appliratiou -for Dbtipoottl Workii Totuitrurtiou Vrroii$
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:-, e �A
Location-Address —.1 or t No.
..�r .
j1 Owner , / Address
d yP g f? 9= q
M Installer ��> Address -^� ;...,,,, i
Type of Buildin.. // Size Lot...t ....--.-f! f S feet
Dwelling 1No. of Bedrooms-------------—=>------------------------Expansion Attic ( ) Garbage Grinder ( )
per.., Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
G-I Other fixtures ------- ---------------------- --
W Design Flow.- ............. ..................#gallons per person per day. Total daily flow--_-..-. �-._-_-_..........gallons.
9 Septic Tank f Liquid capacitv./ '.V-gallons Length................ Width. ...../...... Diameter-...._...__.._- Depth_________.._.
xDisposal Trench—No- -------------------- Width..........r...a._ Total/Len tl .fir..-.! Total leaching area_._-._.._-_----- .sq. ft.
Seepage Pit No.........�._--_...._- Diameter..lA:i_�._.w�*'Dep h"�e�w�nlet��-- ..... Total leaching area-----------------sq. tt.
Z Other Distribution box ( ) Dosing tank ( ) -
1,4 Percolation Test Results Performed bY.......................................................................... Date-----------------------------------
Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water------------------------
G4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.................._._...
------------------ f. ------'. / ......•--........ ---------------------------------------------
f µ
Description of Soil-------------------------•- f ....................... Wit'j/ ' `._ .. ,/---
x
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 Article NI of the State Sanitary Code;.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been.issued by th/bfoard of health./`
Signed.-... f .. t`G�..`v - '--..r------. -------- ----------------
� 1 / Date
Application Approved BY-=---..." /Z..-`�' < / /J"r t: ._. `•-'_... .f 2 7 77 3_
f Date
Application Disapproved for the following reasons:-------------------------------..--f-•--•-------•--------------------------------------- ------•-....-----------
------------------------------------------------------------•-------------•-----•-----------------------------•--•-•----------------....------•------------------------------•--..-..-------------------
Date
PermitNo----------------------------------...................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
t BOARD OF HEALTH
........ ... .' �..........OF.........- ..... h - "�-
Tertifira#e of T11 mVIiaure
THIS IS TO CERTIFY,jThat the Lndividual Sewage Disposal System constructed ( f'") or Repaired ( )
lam-f
i Installers
at...•-----.. -•, t.. `.-- .�-----t------ ------ >---,---•-- _.__ R t -- - -- - :--- -----
has been installed in accordance with the provisions'of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.....-.-.- _--- ------------- dated__.. r _- r`. '.:......_.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUARANTEE THAT THE
SYSTEM WILL F NC ION SATISFACTORY.
DATE..........))-�.- .3 .
4T Inspector ---------------------—---------------------------------=----
s: "
THE COMMONWEALTH OF MASSACHUSETTS ,
BOARD OF HEALTH
.......................:.. ................... v
E
1
-t.......OF........F' . ----
No. -----••--- FEE--:----. -•-•. .........
Bi_sVoiittl Workii Qlonii#rua on Vrrmi#
Permission is hereby granted_.. -...__-; �' •;_-_----/44.Cm:.. ..........-:-....:
to Construct-( or Rkpair ( L) an Individual Sewage Disposal System" �7
at No..-._�____.A-....... _ G-.:-.--= �= ---- 71, �.. ....p lee-----------------------
Street _
as shown on the application for Disposal Works Construction Permit—No............�.{...... Dated-...�y--------�?
------
Board of Health
DATE....-��= ---�.�- ...-/- ----------------------------------------------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
r,
j a�
`. Assessor's map and lot number ...................
.... Sewage Permit number :............... ........•...... .........: :
,� a Qyo,T�Er TOWN 0 F BURNSTAB]LIE' ,,',`-,&qd �.1
r +► l w.. ." t
868BSTA L i �e �a A .3
KUL
2639.
BURDIN
wa ,{
PECTOR
APPLICATION FOR PERMIT TO .............................................0 L � `.Y......... (A) <_c�.�:. .E1.
TYPE OF CONSTRUCTION ..... A. ¢ .
� ..,. .•,; '� . Sri`:}fir
} TO THE INSPECTOR OF BUILDINGS:
The undersigned herebys applies for a permit according to the following information: tk
.L .1.0.5.�. .........................
Location .... ...... .. -
s r Proposed Use ........� /!V�Z.� .......................A`'M.!.� .: ........................................." -� ' (..... .
Zoning District :.!-1.. ....(..........................................Fire District ............. .................
Name of Owner s /d z �'� T ` 5.� .Address .�T ?.$ "`A �. `��1lL.N LT/�$�--�rrr,
Name of Builder ................................. ...................... ..Address ............................. ..
a, Name of Architect Address s
Number of Rooms ............ .....: .. :....Foundations u Q-�.p :...�Il)L 2 TC
Exterior ..... .... C G`
r G.... .. ...I..N..C�..l. y. ��!4 !..�3�.! .F�..........Roofing .
2 f II , i No , l c i/ a r o c y `x
Floors �lA. D.4t.�uD.�....�1.1$IB....T.j ...•...�...1.............................Interior ........�,......................................................................... �
Heating.�f �. I.2e. .... C mr,.V.:..��'�ly ?,..............Plumbing . ..... :./Z :. �. ?°
Z� FM Fireplace .. ..... ... .... Approximate Cost�C�� 3s r
...
... _ _
Definitive Plan Approved by Planning Board _1_v `�_ Z 4 2 20 0
- - --- 19
�-. Area
{�
Diagram of Lot and Building with' Dimensions
Fee ..........
.. .........
- SUBJECT TO APPROVAL OF BOARD OF HEALTHZl—
F V
Lt
t F
�r r
,ws 4 } .
F%
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above _ t
construction.
Name . ........ ...... s
I
97--EXISTING CONTOUR RouTE sA N
x 100.98 EXISTING SPOT GRADE
97 PROPOSED CONTOUR ' ' RAILROAO
. EXISTING LEACH PIT EXISTING WATER SERVICE
CONTRACTOR SHALL PUMP, G EXISTING GAS SERVICE Rock Rd
FILL WITH SAND & ABANDON tJGW --- UNDERGROUND WIRES .G Hite
TEST PIT S n
EXISTING SEPTIC TANK BENCHMARK w
TOP OF TANK, EL.=102.14 c c LOCUS ao
97.99 INV.(OUT)=100.60E LEGEND F
_ a
c O
S 89'35 00" E oA F
J
� � Coach mac. Sl
tl +103.90 > .2 o
OI ( \\\ 21' .91 100.67 x o a = U I
(101.37 x BENCHMARK
BULKHEAD CORNER LOCUS MAP
' �12 8' EL.=103.52 NOT TO SCALE
I 4'DTP-2` '
Ir 1 I 105.41 '1 \� " .� '1 100.95
98.61 x T 71', ; '°°68 W GENERAL NOTES:
E � I ;
LOT 58 I 1�
�l I ` l 35 191 fSF I 103.21 102.31 _ L'r;: `,; :r +1 ,g 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
+ _ BOARD OF HEALTH AND THE DESIGN ENGINEER.
I I �� x 103.10 ' `' f� i. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
W I I OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
98.88 o I N <� +; LOCAL RULES AND REGULATIONS.
L l \ _ 103.86 PA TIO WALK v
- 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
"^ 103,24 �� TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
1n V. ..
02.2 \ x PATIO
. N J.: ': :`.>. ....,.... -G o DESIGN. ENGINEER.
J I•. . .: rns 103.52 x 0 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
PA .104.°
99,07 ' 1 DRII/EWAY EXISTING I fence + 1oa:7pi/ o p ENGINEER BEFORE CONSTRUCTION.CONTINUES.
1o2.os GARAGE HOUSE(#120) I /
5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM.
io3.i§.•., , T.O.F.=105.2E x 103.36 r L 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
�0 I THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
Q� x 101.46 �� l � HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
+ \� 102.16 x 7. WATER SUPPLIED BY TOWN WATER SERVICE.
►�[`-I 103.�� � + � r 0 � 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
99.46 4.49 _
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
1,9� �Si 1o3.se� AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
7 I �� x 104,70 DIRECTED BY THE APPROVING AUTHORITIES.
f• \�
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY'
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
10019Q (`'3 +101.5 a �� �� CONSTRUCTION.
<\� `w' 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
+101.22 �� �
f IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
-�I OOOR�p x 101.81 �� 3 � REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
201.00' 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
N 89*35'00" W x 105,07 INSPECTED BY A LICENSED SOIL EVALUATOR PRIOR TO BACKFILL.
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
100.39 101,09
102.31 edge of pavement 1o3.as :� IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY.
,
104.42
COACH LANE PARCEL 'ID: 298-088
MT NTET.E y PROPOSED SEPTIC SYSTEM UPGRADE PLAN
CIVIL 120 COACH LANE, BARNSTABLE, MA
No. 35109
Prepared for: DiBuono Sewer & Drain, 35 Content Ln., Cotuit, MA 02635
Sl
OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO.
DOWD, ROSALIE A TR Engineering Works, Inc. 1"=30' P.T.M. 282-18
( ( � l 120 COACH LANE 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
Z\ BARNSTABLE, MA 02630 (508) 477-5313 12/17/18 P.T.M. 1 of 2
J
is I
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
!1� FINISH GRADE SHALL NOT BE < EL:98.20
SEPTIC TANK FOR A DISTANCE OF 15' AROUND THE —
INSTALL RISERS & COVERS OVER INLET PERIMETER OF THE S.A.S.
AND SET TO 6" OF FINISH GRADE. PROPOSED D-BOX PROPOSED S.A.S.
INSTALL WATERTIGHT RISER & PROVIDE TWO ACCESS MANHOLES TO WITHIN 3" .EXISTING GARAGE
OF FINISH GRADE FOR INSPECTION PURPOSES
' T.O.F.=105.2t COVER SET TO 6" OF GRADE HOUSE#120)
F.G. EL.=103.3t F.G. EL.=101.6t T.O.F.=105.2f
F.G. EL.=103.2t F.G. EL.=102.Of
MAINTAIN 2% GRADE (MIN.) OVER S.A.S.
� n n� i n t nn g PATID
' L = 13' L = 5,
® S=1% (MIN.) ® S=1% (MIN.)
4"SCH40 PVC 4"SCH40 PVC
6" 7P�
as � as \
am
14 1 8" 6B 000BB ��
EXISTING 48" uoul0 - ^� a
LEVELADD 4'
���� INV.=99.87 PROPOSED INV.=99.70 ! 4.8' 4' ---
EFFECTIVE WIDTH = 12.8' I a
INV.=100.80f DCn
-BOX I.
. .. . . .. . . . INV.=97.70
EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS I I
SURROUNDED WITH STONE AS SHOWN I a I
H-20 RATED
TOP CONC. ELEV.= 98.8t
BREAKOUT ELEV.=98.20 — SEPTIC LAYOUT
NOTES:
INV. ELEV.=97.70 as®a
eases aBaaa
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE aaaa aaaaB
INVERTS, PRIOR TO INSTALLATION. BOTTOM ELEV.=95.70
4' 2 X 8.5'=17.0' 4'
2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE 4' MIN. OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0'
ON A MECHANICALLY COMPACTED SIX INCH CRUSHED PERVIOUS MATERIAL
STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 5' MIN. ABOVE GROUNDWATER LEACHING SYSTEM SECTION ®®®® 0
3) INSTALL INLET & OUTLET TEES AS REQUIRED. BOTTOM OF TP, EL.=90.2 — ®®®®®® ® ®®®® 37"
4) CONTRACTOR SHALL INSTALL A GAS BAFFLE ON 3/4" TO 1-1/2" DOUBLE w ®®®®®® ® ®®®
THE OUTLET TEE. WASHED STONE N Z ®�®®®® ® ®
3" LAYER OF 1/8" TO 1/2"
SEPTIC SYSTEM PROFILE DOUBLE WASHED STONE 102"
(OR APPROVEf! FILTER FABRIC)
DESIGN CRITERIA SOIL LOG 4" KNOCKOUT
DATE: DECEMBER 13, 2018 (REF#15,856) 20" DIA. COVER
NUMBER OF BEDROOMS: 3 SOIL EVALUATOR: PETER McENTEE PE(SE#1542)
SOIL TEXTURAL CLASS: CLASS I WITNESS: DONALD DESMARAIS R.S.HEALTH AGENT / 58"
4" KNOCKOUT 4" KNOCKOUT
DESIGN PERCOLATION RATE: <2 MIN/IN ELEV. TP-1 DEPTH ELEV. TP-2 DEPTH 0
(0.74 GPD/SF LOADING RATE) 100.7 A 0" 100.7 A 0"
DAILY FLOW: 330 GPD LOAMY. SAND LOAMY SAND 4"' KNOCKOUT
DESIGN FLOW: 330 GPD 99.9 10YR 4/2 10" 100.0 10YR 4/2 8„
GARBAGE GRINDER: NO B B
330 LOAMY SAND LOAMY SAND 500 GALLON CAPACITY, H-20
LEACHING AREA REQUIRED: GPD LOADING
( ) = 445.9 SF 10YR 5/6 10YR 5/6
74 GPD/SF 98.2 Cl 30" 97.7 Cl 36" CHAMBERS
EXISTING SEPTIC TANK: 1500 GALLON CAPACITY PERC
COARSE SAND 30/48" N.T.S.
PROPOSED DISTRIBUTION BOX: 1 INLET, 3 OUTLETS 2.5 Y 6/4 COARSE SAND
USE 2-500 GALLON' LEACHING CHAMBERS IN SERIES GRAVEL/ 2.5 Y 6/4 PROPOSED SEPTIC SYSTEM UPGRADE' PLAN
COBBLES GRAVEL/
SURROUNDED- BY DOUBLE WASHED STONE ON ALL SIDES 93.7 C2 84„ 93.7 COBBLES 84" 120 COACH LANE, BARNSTABLE, MA
SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. C2 Prepared for: DiBuono Sewer & Drain, 35 Content Ln., Cotuit, MA 02635
BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. MED. SAND MED. SAND
2.5Y 6/6 2.5Y 6/6 Engineering by: SCALE DRAWN JOB. NO.
TOTAL AREA:..............................................................471.2 S.F. 90.2 126" 90.2 126" Engineering Works, Inc. NTS P.T.M. 282-18
DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD NO GROUNDWATER, PERC RATE: <2 MIN./IN. 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 12/17/18 P.T.M. 2 Of 2