HomeMy WebLinkAbout3965 MAIN ST./RTE 6A(BARN.) - Health ,
3965 RT. 6A/MAIN ST., BARNSTABLE
A
r
D „ ..
(J_5- 03Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments =a
~�
3965 Main Street(Rt.6A) i:�•'
Property Address -
r�
Lawrence Cuzzi ,.,.
Owner Owners Name
information is bl t arnsae MA 02630 5-31-19 "
required for every B rrWl
page. City/Town State Zip Code Date of Inspection '
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form. uil+Il+brpr�
OF M r4
Im rtant When
filling out forms A. Inspector Information 13S(1 b wo�., sG,
on the computer, ��;' JAMES
use only the tab James D,Sears A nr�
key to move your Name of Inspector U t y
cursor-do not Capewide Enterprises
use the return Company Name
key. �Sp�G�e```�
153 Commercial Street �h,"�ira►,,,,,,,,,,,�a�"`�
ICI Company Address
Mashpee AAA 02649
CItyfTown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15,000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true,accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
6-1-19
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.
t5nsp.doc•rev.712612016 Title 5 Ofllclal Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Z a5ed xeJ dH EE:ZZ 61,0Z t0 unr
Commonwealth of Massachusetts
Title 5 Official Inspection Form
+' r
�) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
✓� 3965 Main Street (Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
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:
The system is a main pool and two pits.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass,
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
£ a6ed xed dH ££ZZ 660Z t70 unf
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F�
3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page. Citylfown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumpslalarms 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). he
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:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 18
t, a5ed xed dH ££:ZZ 660Z b0 unf
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
01F 3965 Main Street(Rt.6A)
. :
Property Address
Lawrence Cuzzi
Owner Owner's Name
information Is required(or every Barnstable MA 02630 5-31-19
page. CitylTown 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 wall".
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.7/2&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
5 a5ed xeJ dH CUE 660E t?0 unf
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
�a ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in expepoW is less than 6" below invert or available volume is less
than Y2 day flow o,T
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
El ® 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.dm•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
9 a5ed xeJ dH MZZ WZ b0 unf
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main Street(Rt.6A)
u Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C,5 or failed
under Section 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 aU 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, excluding the SAS, located on site?
® ❑ Were the manholes uncovered, opened, and the interior
inspected for the condition of the 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)]
t5inspboc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Dispcsel System•Page 6 of 1B
a5ed xe� dH b£:ZZ 660Z b0 unr
Commonwealth of Massachusetts
YKTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main Street(Rt-6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): NA Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Main pool and two pits.
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
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available last 2 ears usage d 2017- 6,000Gal's
g ( y g (9p )�' 2018-6,000 Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
I5lnsp.doc-rev.V2612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16
g a5ed xeJ dH t UE 61•0Z t O unr
I
Commonwealth of Massachusetts
, R Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3965 Main Street(Rt 6A)
`J Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
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 occupancyluse: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ® Yes ❑ No
500 Gal.
If yes,volume pumped: gallons
How was quantity pumped determined? Gage on Pump Truck
Reason for pumping: Part of Inspection
I
t5lnsp.doc•rev.7/26/2018 Title 5 Official Impaction Form:Subsurface Sewage Disposal System•Page 8 of 18
6 a5ed xed dH bEZZ 610Z 170 unf
c Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main Street(Rt.6A)
u' Property Address
Lawrence Cuzzi
Owner Owners Name
information is
required for every Barnstable MA 02630 5-31-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt,)
4. Type of System:
® soil absorption system
® MW 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:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
3,
Depth below grade`. feet
Material of construction:
❑ cast iron ®40 PVC ❑other (explain)
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
` Pipeing is 4"PVC SCH -40.
t5insp.doc rev.7126/2018 Title 5 Official Inspecdon Form;Subsurface Sewage Disposal System Page 9 of 18
0l• a5ed xed did b£ZZ 660Z b0 unf
Commonwealth of Massachusetts F
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page_ Cityfrown State Zip Code Date of Inspection
D. System Information (conQ
6. Septic Tank(locate on site plan):
Depth below grade: 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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.),
t5insp.doc•rev.712612018 Tide 5 Ofbcial Inspection Form:Subsurface Sewage Disposal System Page 10 or 18
6 6 abed xed dH bEZZ 6 t0Z t O unr
`y Commonwealth of Massachusetts
Title 5 Official Inspection Form
l/i, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V 3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page. City/Town Slate 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
tSinsp.doc-rev.72812018 Title 5 Official Inspection Form:Subsu,,lece Sewage Disposal System-Page 11 of 18
Z 6 a5ed xed dH 9E EE 6 60E 170 unr
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owners Name
information Barnstable MA 02630 5-31-19
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 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
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.):
t5insp.doc-rev.712612018 Tifle 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 18
£6 abed xed dH S£ZZ 660Z 1V0 unf
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page. Gty/,rmn State Zip Cade Date of Inspection
D. System Information (cunt.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overfiow cesspool number:
❑ innovativelalternative system
Type/name of technology:
t5insp.doc-rev.7126I2018 Title 5 Ofridal Inspection Form:Subsurface Sewage Disposal System•Page 13 0118
b6 abed xed dH SEZZ 660Z t,0. unr
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface!Sewage Disposal System Form • Not for Voluntary Assessments
3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi '
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cant.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
Leaching is two pits piped inline. Pit#1 at 20" below grade 20" water w/outlet tee. Pit#2 H-20 at
24" below grade dry. Both pits have 5'stone, Pit#1 18"cover. Pit#2 32"cover.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration 1
Depth— inert
4"
D h to of liquid to inlet invert p p q
Depth of solids layer 4„
2"
Depth of scum layer
6'
Dimensions of cesspool
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,
etc.):
Main pool 6' Deep w/steel cover at grade. In and outlet tees. Pool was pumped w/inspection.
t5insp.doc•rev.71262D18 Title 5 official Inspectlon Form:SubsurNce Sewage Disposal System-Page 14 WE
56 abed xed dH S£ZZ 660Z t'0 unr
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V 3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page. Cityfrown 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.712612018 Tide 5 Official Inspection Form:Subsurface Sewage Dlsposal System•Page 15 of 18
9t abed xed dH 9£ZZ 660Z ti0 unr
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface!Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
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
R�Ae
�Rt`K 5
U
£D
g o
60 !::
0
a,34
t5insp.doc•mv.7126/201a Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Li, abed xed dH SE ZZ 6 60Z V0 unr
i
y -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
n
V 3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Owner's Name
information is required for every Barnstable MA 02630 5-31-19
page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Nc
Estimated depth tough ground water: 2
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:
Abutting property drops off 25'.
T
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
9 t a5ed xeJ dH g£ZZ 61•0Z t,0 unr
Commonwealth of Massachusetts
Mig Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main Street(Rt.6A)
Property Address
Lawrence Cuzzi
Owner Ovmer's Name
information is required for every Barnstable MA 02630 5-31-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist) completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 15 or attached
For 15: Explanation of estimated depth to high groundwater included
�v
to0 Tit r-
PrT q
1Sf
ly
oY
t5lnsp.doc•rev.7126/2018 Title 5 Of6cis,Inspection Form:Subsurface Sevmge Disposal System•Pepe 18 of 18
El, a5ed xed dH 9E:ZZ 61.0Z b0 unf
°. Commonwealth of Massachusetts 33S-b3�f
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is �/
required for every Barnstable Ma. 02637 November 29,2015 c
page. Cityrrown State Zip Code Date of Inspection tT'
rya
Inspection results must be submitted on this form. Inspection forms may not be altered in any C.0
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms �'#
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Thomas Roux
use the return Name of Inspector
key.
Company Name
89 Mayflower Lane
�I Company Address
East Wareham Ma. 02538
City/Town State Zip Code
774-678-9066 S14531
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspector's Signature Date.
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
�a VS
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is required for every Barnstable Ma. 02637 November 29 2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/ahvays complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15,304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N,ND)for the following statements. If"not ,
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
3965 Main St. (Rte.6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is Barnstable Ma. 02637 November 29 2015
required for every >
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c . 3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is Barnstable Ma. 02637 November 29,
required for every 2015
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is required for every Barnstable Ma. 02637 November 29 2015
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone I,of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within.400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3L13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is required for every Barnstable Ma. 02637 November 29,2015
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ 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:
® 0 Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 for example: 110 +330 gpd
( p gpd x#of bedrooms):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
• ,M ..' 3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is Barnstable Ma. 02637 November 29,
required for every 2015
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (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: current
Date
Commercial/Industrial Flow.Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is required for every Barnstable Ma. 02637 November 29,2015
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the 1/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
® Other(describe):
Three pit structures in series. The first ads as the septic tank and the second and
third ones act as the SAS.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM ' 3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is required for every Barnstable Ma. 02637 November 29 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (f known) and source of information:
Age of system varies.The system was last worked on in December of 1986.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.75' (at the first structure)
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10,
feet
Comments(on condition of joints,venting,evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.75'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: 5' in diameter X a depth of 6'.
Sludge depth:
2"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
Information is Barnstable Ma. 02637 November 29,2015
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
58"
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 18"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
(Structure 1)The inlet and outlet tees are in good condition.The first structure acts as the septic tank.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuui
Owner Owner's Name
information is required for every Barnstable Ma. 02637 November 29 2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons �I
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Selvage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is Barnstable Ma. 02637 November 29,
required for every 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.):
There is no D-Box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
(See page 15) Structure 2 does not exist. Structure 3 was full of water. Structure 4 was completely
dessicated. Structure 4 provides enough capacity. The entire system was dug up with an excavator.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�,M s 3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is Barnstable Ma. 02637 November 29 2015
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology.-
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation,etc.):
No evidence of hydraulic failure in the last structure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is required for every Barnstable Ma. 02637 November 29,2015
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
wmma Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments
3965 Main St. (Rte.6A)
Property Address
Lawrence Scuzzi
Owner Owners Name
information is Barnstable Ma. 02637 November 29 2015
required for every ,
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cunt.)
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
Poll>6-6 le
H'QttS
.31
25
4Cl •• w.41 S 7S�N.a
i j'� lC H za )
e j3 w�.S +wve
,j To
tSins-arts rdle 5 OW=W bspedim Form:Subsurtaee Sewage Dill System•F+ae 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is required for every Barnstable Ma. 02637 November 29,2015
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water .
® Check cellar
® Shallow wells
Estimated depth to high ground water:
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:
From a previous Title 5 report on file at the BOH.
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
From a previous Title 5 report on file at the BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
/ µ
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,..•''a 3965 Main St. (Rte. 6A)
Property Address
Lawrence Scuzzi
Owner Owner's Name
information is Barnstable Ma. 02637 November 29,
required for every 2015
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary:A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
ro a
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 11
f
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
COPY
_ COMMONWEALTH OF Mr'1SSACIiUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON 1vIA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Ads: 3 Name of Owner C;01 1l M;
1 ,C es Addrs of owner: o. i3,• 9.3 y
Date of Inspection: y//0/oc,
AAN
Name of Inspector:(Please Print) Troy Williams
6 3 7
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
0.2 '
Company
Nana: Troy Williams Se tic Inspections
Mailing Address: 19 Hummel Drive, So. Dennis, MA 02660
Telephone Number: (508) 385-1300
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature:/ - Date: V//a /o o
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to efts
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
revised 9/2/98 P... r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: 3965 Route 6A, Cummaquid,MA
Dace of Inspection: Cindy Milburn
April 10, 2000
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303,exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES: /N/-1
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.
Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 •
Page 2 of I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prey Address: 3965 Route 6A, Cummaquid, MA
Ownw: Cindy Milburn
Date of Inspection: April 10, 2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A//I .
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised. 9/2/98 •
Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
3965 Route 6A, Cummaquid,MA
.Property Address: Cindy Milburn
Owner: April 10, 2000
Date of Inspection:
D. SYSTEM FAILS: N119
You must indicate either -Yes' or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due-to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. -if the well.has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE.SYSTEM FAILS: A111
You must indicate either"Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greeter(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98
Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3965 Route 6A, Cummaquid,MA
Owner: Cindy Milburn
Date of Inspection: April 10, 2000
Check if the following have been done: You must indicate either "Yes" or "No- as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped-forat least two weeks and-the system has been•receivingirormal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
/ inspection.
JL _ 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.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
✓/ _ All system components, excluding the Soil Absorption System, 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.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable!
[15.302(3)(b))
The facility owner(and .occupants,if different from owner)were.provided with information on the.
p p proper maintenanceof
Subsurface Disposal Systems.
revised .9/2/98 •
Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: 3965 Route 6A, Cummaquid,MA
Date of Inspection: Cindy Milburn
April 10, 2000
RESIDENTIAL: FLOW CONDITIONS.
Design flow: //0 g,p.d./bedroom.
Number of bedrooms(design): Number of bedrooms(actual):.3
Total DESIGN flow 330
Number of current residents:
Garbage grinder(yes or no):/v t1
Laundry(separate system) (yes or no):A10; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):,/0.
Water meter readings,if available(last two year's usage(gpd): 9 g /9 9 a//o 1 y P/ 9
Sump Pump(yes.or no):�U
Last date of occupancy: yP; ,
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd ( Based on 15.203)
Basis of design flow
Grease trap present:(yes or no)_
Industrial Waste Holding Tank present:(yes or no)—
Non-sanitary waste discharged to the Title 5 system: (yes or no)—
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: /f
Pc! /�cd� K✓�» �yr1 by u TL C,
System pumped as part of inspection:(yes or no)_Mo
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
ZOverflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed Of known)and source of information: Q r ..;„ w( to L
L G4-55roo i %. �!� P` 'f c.�l.l../ cr io ) J,+. . t3.r.J t-4 -�dc)<.A /21 cArc
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corTfinued)
Property Address:
Owe: 3965 Route 6A, Cummaquid,MA
Date of kupection: Cindy Milburn
April 10, 2000
BUILDING SEWER:
(Locate on site plan)
it
Depth below grader
Material of construction: cast iron V140 PVC Vother(explain)
Distance from pnvate water supply well or suction line /1/ -3
Diameter u
Comments:(condition of joints, venting, evidence of leakage,etc.)
in
SEPTIC TANK: /9
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ ls.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structuret4ntegrity,
evidence of leakage,etc.)
GREASE TRAP:
/ 9
(locate on site plan)
Depth below grade:_
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:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
A
revised 9/2/98 Page 7ofII •
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 3965 Route 6A, Cummaquid,MA
Date of Inspection: Cindy Milburn
April 10, 2000
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/day
Alarm present
Alarm level: Alarm in working order:Yes No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX-,&/,g
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note-if level and distribution is equal,evidence,of solids carryover, evidence of leakage into or out of box,etc.) -
PUMP CHAMBER:_A//3
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
y
revised 9/2/98 Page 8ofII •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 3965 Route 6A, Cummaquid,MA
Date of Inspection: Cindy Milburn
April 10,2000
SOIL ABSORPTION SYSTEM(SAS):,2
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type: �I ,x6 ' L i, 3 w; +-L
leaching pits, number:
leeching chambers,number:_
leaching galleries,number:_
leaching trenches,number, length:
leaching fields, number, dimensions:
overflow cesspool,number•_9oe_ G 'xs 'ate«✓, ssr,,i.
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.)
w+s� a �� t /ten I^ P; + A,. % ,<"--4 I � 1�,.
. CIA I r r G/tom. 6 v+ w, i�. �-
S/. G )-
riLs_"�;
�!ct f-s..- L✓t'/ail l 0. .CESS O --f-(Vht 0, " S o t z
(locate on site plan) w r u r�• Nv ✓ S v w I u: <„ e d�' .� �« v v _
1 s o -'fib
Number and configuration:C2 he- yfnc., c,t-s 5 oa 1
Depth-top of liquid to inlet invert: Y" p
Depth of solids layer: y/r
Depth of scum layer:_ y"
Dimensions of cesspool: 6 ' p(141 A X S irI K�
Materials of construction: 'd
Indication of groundwater: /Vo"F
inflow(cesspool must be pumped as part of inspection) L K L. '� ,,, �� s ,", Jr •���{ w
y)roc.S c r. }� rr•► .c v � h ��-�c �� W � Lr o c_✓a !mot c.. �-� u /C S/tii.�
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
►�� U �nirlti��,..� pu/rp:.., of�Ksp Vu 1 :S �� C t�/�MCnGCL��,
PRINY:._.�y�,9
(locate on site plan)
Materials of construction: i
Depth of solids: Dimensions:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 3965 Route 6A,Cummaquid,MA
Date of Inspection: Cindy Milburn
April 10, 2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
34 L'i;,R
r
revised 9/2/98 Page 10ofII •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corrtir
Property
�Y Address: 3965 Route 6A, Cummaquid, MA
Date of kupection: Cindy Milburn
April 10, 2000
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited ,W 2-y a 1. 7
Observation Wells checked zolye 5
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater I f"Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V Observed SiteiAbutting property,observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
V/Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
l 4- (J S G 5 r�quo S S 4 0 / `j ro r...t c.J�.LLf �..� w o.u:r .S�- i c, a r e-
r7s K ...�. tcA N'rctS.rrs.I\ �tah,'ti �.r.-.fit .TC! �7✓u�o� 61t ��-F�a..vA 6O _
/41
i as O CY�O L, �4;� f o�'� ll /o✓O/�.i'_'-c-✓`L�.0.�. 7./�tO ,..�V�sJ`wo; {n uo.'r.� oA
P^(o �J // Ar o- CX .
,� �1,� � C�✓f!•J �..all ri✓q-'-1-'�'1� �I'-L{/�7 0 4 0.^�
/�L.w_ ^77�"►-� ci J" �i^S fc,���io... V ra.�,..d ww}-w 0.�J .i S�-r�.�., �.'S c:rt
_ � 11 Kc ci �c �� 1✓ � rti
revised 9/2/98 •
Page 11 of 11
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4pfitation for Disposal 6pstem Construttiou jermit
Application for a Permit to Construct( ) Repair(Yj Upgrade( ) Abandon( ) ❑Complete System X Individual Components
Location Address or Lot No. 34,5 mA ii S4 PT cA Owner's Name,Address,and Tel.No.
LAURjS1C,9 CO2mc-1
Assessor's Map/Parcel 335
PoeovLxg cuo4,wA of mA ox3
Installer's Name,Address,and Tel.No. SOS-107_NO 7 Designer's Name,Address,and Tel.No.
153 T- NAS6PEZZ P 1A
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) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
l r4cxlc C.t E j it t`fvv� G� G�6U
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health
i ej Q Date
Application Approved by Date
Application Disapproved y Date IV
for the following reasons
Permit No. Date Issued
.k 0No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4pliLatlon for 33isposal 6pstem ConstrUetion permit
�/ tw.
Application for a Permit to Construct( ) Repair IN Upgrade(�) Abandon( ) ❑Complete System 9 Individual Components
Location Address or Lot No.39/,P5 MAl xu sT Pcr cA Owner's Name,Address,and Tel.No.
mZ1 , 4-AujRW� cozy—r
Assessor's Map/Parcel 33 s 0z, P O 4ov wL,4 C oo4sf A0-L)( MA O a<,3'7
Installer's Name,Address,and Tel.No. 5 oS-47 7-9S-17 Designer's Name,Address,and Tel.No.
CAeGWIPS E7L76CPA15'6r Lx-C. /^
!S3 e-0W4A�a.tA-L 5T- l�, kP&- �1A
Type of Building: 4
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) gpd Design flow provided gpd
Plan Date ' Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
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 and not to place the system in operation until a Certificate of
i
Compliance has been issued by this Board of Health.
Si e , o Date
Application Approved by / Date
v
Application Disapproved by 41Date
for the following reasons
,t ermit No. zAL Date Issued ;
THE COMMONWEALTH OF MASSACHUSETTS
f\ U� �� BARNSTABLE,MASSACHUSETTS <
Ceftifirate of Compliance �.
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded
Abandoned( )by C A DE t�l D6 t; �F2tSK L-1�
at 39(,5 A4 h-1fU SST A.T(.A I34W. has been cons�t cted' accvit
cep
with the provisions of Title 5 and the for Disposal System Construction Permit No� e
Installer CAPC (W E7X-PI All 4S L.L-C.. Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system will fund io designed. Q
Date (' / Inspector /�� T
----------'---------------------------------------------------------------------------------- '------` ----
No. Fee
LX1 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Bisposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(,�) Upgrade( ) Abandon( )
System located at 3 9 &5 P. 4 ( m A-w s
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.
Provided:Cons ct'4n us e co eted within three years of the date of this permit. /
Date f2 Approved by !
No. 0 F�s.............F......1�
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEAL H
f� .........OF......l IP�� a .../ ---- ------------------------_---
V
Appliration for %gvaaal Works Tomtrurtinn Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (ill an Individual Sewage Disposal
System at:
........................---•--------------•--------------------------------------------•--
e Location-Address or Lot No.
- - - �2! -•--------- --
r—+ Ow Address
.......Vjo?.%74Vh.......A&....... ........
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling�No. of Bedrooms..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ___________________________• No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures--------------------------------- .
W Design Flow............................................gallons per person per day. Total daily flow.,...........................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_______---______ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------------------_- Diameter...._............... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_________-_____----_--_.
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x Description of Soil------.---- ,�' � _.. - -
.-... ' w ----------------------------------------------------- ---------•---------------- ------
------------------------------------------------------------------------------------•--• -------•----••---• }-
V Nature of Repairs or Al ra ' ns— twpr when applicable____ 'G _____._ wv....... _.._ :___/ _...._..............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T;'L% ; of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beep issued bDv th bo rd ff'health. c
Signe ... _. .. __ . .
Bate/
Application Approved By............................... ....•---•----------.....•••-•------•...................--•---.... -•--------- ..;o/-�
Date
Application Disapproved for the following reasons:..............................................................................................................
•--------•----------------•-----------------------------------------------------------........
Date
PermitNo....... �-------- .......................................................�-.�.. .._.. Issued.
Date
I L
Y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD �9F HEALTH
Appliration for Disposal Works Tontrn.rtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (,k") an Individual Sewage Disposal
System at r
................H to ................ . t / mod- .....Y s .. ......... ........... .
' Location-Address "- or Lot No.
.. - -------------- .................................................................................................. .
c.......... Address
! 11-dt tV . bl"------•-- ---•----------------------------•--•------•-•---------•-------------.-----------------------------
Installer Address
Type of Building Size Lot.....................:......Sq. feet
,., Dwelling ino. of Bedrooms....... .......................:...Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _________________________- No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures -----------------------------••-
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity------------gallons Length................. Width................ Diameter------.---___-_- Depth................
x, Disposal Trench—NTo. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank-
Percolation Test Results Performed by.....-----------••---•••--•..........-••--•............--•-----•••••..... Date.........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes.per inch Depth of Test Pit.................... Depth to ground water........................
a -1....... --..---- ............................................
Description of Soil......d 'rr' � e ,'�........... Y...............................................
U ........................................ .... ....... .._..__....._...._ ......... ........_
•----•----•--- ----------------------------------------- -----------------------------•---------------- 1 �! r 1
U _ Nature of Repairs ` A� ''
er ons— n e. when applicable_. . °'✓-' fr............................................. .* ...__.......
--•---------%� ---- = ,,�` ............... - r ...:.------------------------------------------------------------------------------------------------.......---------
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of T 'Li:p of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certincate of Compliance has been issued ley th board of health .
r� /��
/erg,¢
:pt f'R�i 1y�f � .................................
. .......
I Date
Application Approved By --------------------------------------••••-••._...-•.-• ••---••-•-
Date
Application Disapproved for the following reasons:-----•--------••----•-•-------•------------------------•----------------------------------------------•-•_...._
--------------------------------------------•------•-----•------•---------....-------------•-------------•••--•••••••-•--•••----•••-•--•••••----•••••-•-•--------••----•-•------••••••••---•----•---••--
Date
PermitNo------. e...........1--2-�------ Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.,fir � r
............
✓.l;m&v '+....OF....� w���h�.�,d!
Trrtif irate of Tompliatta
THIS-L&...TO CERTIFY hat thef no vidual S wa e Disposal System constructed or Repaired
-
g P �' ( ) P ("�"�
by..............v� & e L. � '
................................................
sf -Instal eg
l f
............•••-•-...... •---•-
has been installed in accordance with the provisions of +1 LE 7 of-The State Sanitary Code as described in the
application for Disposal Works Construction Permit N�-TQ....1.2.0..77. dated__-..!! l.Z_%-------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST�S A GUARANTEE THAT THE
SYSTEM. WILL FUNCTION SATISFACTORY.
DATE . •••.• -•....(.`.' .. Inspector_.. :: -------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/'/. OF
...
�T
.......---•- -2. •-0�
FEE........................
Disposal Works T.Wnotrurtiou orrmit
Permission is hereby granted..................'_._. ._.........l 11 ' It,-- = --• .
to Construct ( ) or Repair ( . •) an Individual Sewage Disposal System
at No - .
Street �_
as shown on the application for-Disposal '"Torks Construction Permit N9=&.-1287 )_ .JJ_Dated� JAJ.56.......
No t Board o2 Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
A, q
a
TOWN OF BARNSTABLE ��
`g.00TION �,` A-ZF SEWAGE
9
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. JA
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)`-���j.- �(�t Ssize) ��j�'
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER_
BUILDER OR OWNER
DATE PERMIT ISSUED: `b,4710
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
r
d� ti
A t
LOCUTION ' SEW&CtE PER-MIT UO.
INST&LLERS U&NIE ADDRESS
BUILDER 5 Q &MF- P, ADORE Ss
DNTE PERNAIT 15SUED
DATE COMPLI &MCE ISSUED ;
4
�^
._ �
.' � �
�•- _�1
�_
C TOWN OF BARNSTABL�4-) �,��
LQCATION / s` / ✓� SEWAGE #
VILLA DE— �J�vim•a S ✓ of ASSESSOR'S MAP & LOT.
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMPTDATE: f��lo �g 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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
��
��" l�
. �
6r
� �
f s
r �.� �
�- W
S
��_ :.
�> C-
L_
�/'\ I
\` ��
l� � _ __
c —� N
. �
�=
�„
t � �
� '�
,:,
h
(�. _ �✓
THE COMMONWEALTH OF MASSACHUSETTS
P4Q,
BOARD F HEA I T
. N Appliration -for 43hiputittl Workii Tongtr rtio'n y1junift
Application is hereby made for a Permit to Construct.-(- )' or -Repair ( ) an Individual Sewage Disposal
System at:
........ !'g-------1� Lc.�,�s.. .�' f1.1_. ........----.. (`.. ..&L!:�_)........ ------.•'�--�1---v
Location-A e_ss or Lot No.
- - - _
ner Addres _
Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( )
---• a Other—Type of Building ___________________________ No. of persons.-_______________________-__ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- --
W Design Flow............................................gallons per person per day. Total daily flow............................................ allons.
WSeptic Tank—Liquid capacity--___---___gallons Length---------------- Width................ Diameter__-____-_--____ Depth--------___-_.
x Disposal Trench—No_____________________ Width--_--------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter____________________ Depth below inlet__ ....._ _____ Total leaclih area------- ----------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) (�� G 8' �G "z
a Percolation Test Results Performed by-------------------------------------------- -----•---•-•--•---•--•• Date----•------------
I---------------------
Test Pit No. 1----jx;�......minutes per inch Depth of Test Pit.................... Depth to ground water________________________
fs, Test Pit No. 2----------------minutes per inch Depth of Test Pit..................... Depth to ground water------------------------
P4 ---------- ---------------- ------------------------------------------------------------------------•---•--------•-------•--------...._-----•--------•-----
ODescription of Soil-----------------------------------------------•------•----•-------------------------------------_----------------------------------------------------------- ---------
x
tJ ----------------------------•--•-------•-•-•---•--•--•------------•-------••-------•-----------------•---------•-------•---•-----•----------------------------------•-----------------
W ------•-------------------------------------------------•------•-----------------------------------------i
---- ---------_-__.___- ------------------------------------------- ._..•_.._..
U Nature of Repairs or Al erations—An wer wh n applicable- ----- -____-/&__
WWI�+ P t � 1 ' q �� ---------------------------------------------------------------------rr- -----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate.of Compliance.hAbeens by t e board of he Ith.
SigneApplication Approved By-------
--- - --- - --
Date
Application Disapproved for the following reasons:_-_____
----------•-----•---------------•--------._._.____...-.--•---...__.-....._...-•----. --•------•-•--
n;
-•-------• --------------------------------------------------•----•----•-••-••••---•--------------•-•--..----------------------------•------------•-------•-•-••--•------•--•-----•-._._..•------------
Date
PermitNo......................................................... Issued.........................................................
Date
---------------------------- ------------------------=-----�
I f
�q r u � fc �� �✓u r 6 N
No.......... ............ FEE... j.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. . ......... .. .OF.........................................
t ���ly ..� lirtttion f nr UtoVoiiat Works Cn m #r r iuYt Vrrttti
` Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy at: `
f
Location- dress or Lot No.
....................... .......•----.._......................................................... -•----•---••--•-•-•••---•.....-••-•-•-•---------------••----•----
W / Owner �) Ad es
••--6 G '.......... F��.6��-rk-�'i•�� " ----t •..........
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------- _-__----.-----Expansion Attic ( ) Garbage Grinder ( )
'-
pa, Other—Type of Building ---------------`____-_-____ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
al Other fixtures
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. .
WSeptic Tank—Liquid capacitv__------__gallons Length---------------- Width..__.._._.__.. Diameter................ Depth-.-..--.__.----
x Disposal Trench—No--------------------- Width-------------------- Total Length....._.............. Total leaching area--------------------sq. ft.
3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft.
z Other Distribution box ( ) Dosing tanklly'
Percolation Test Results Performed b ______________________________I.�s�+.E'.._____--._, Date._f--`L�'.�".:________.___.___.__..
a Y !'
Test Pit No. I....../-�-----minutes per inch Depth of Test Pit_______ _________ Depth to ground water.._-_-._.-._----..------
LT, Test Pit No. 2......." _____minutes per inch Depth of Test Pit____________________ Depth to ground water--------------------
---------------------------- ---------------••------------------...............-•-•--........---•--.._..._-•-••-................................... -----•--------•-•---
ODescription of Soil------------------------------------------------------------------------------------------------------------------------- -----•---••-----•----------------------------
V •-----------------•---•----••---------------------••-------------------•----.-.----------------------•----•----------•--•---•-----•----•----••--•------••-•--••-•-•------------------••-•---------------
•----•-------------------------------------•-----------------------------.----.----------------•----------••----------...
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 Article XI 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 e boar of health.
igned C .................
J Application Approved BY f�-�1 ` . " Date
1-C-------------
Date
Application Disapproved for the following reasons:----•-------------------------------•---------------------------------•-•-•--•-----------------•-------••-------
---------•------•--•-----•------------------------------------•---•--•---••----••--•------•-•-----------•............•-----------•----•. •--•---•--.....--------.---.. --------------------------.......
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... ..........OF............ ?5..%. t�t�?��..............................................
Qrr#ifirtttr of f�>amplitturr
TH,I,S I-S TO CERT(FY, That the Individual Sewage Disposal System constructed ( �r Repaired ( )
.a// ! 4Installer
at ---------.lr............... ..« -L--------------------------------------------------------------------------------------------------------------
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---..��
----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY. f 1 1
DATE----------- --'---.. ---- ----7. .................................... Inspectof--------------== t .....)
—`C::----•------------------
TH.E COMMONWEALTH OF MASSACHUSETTS
BOARD OF
l� HEALTH
_ t�
. -....`fix.......OF............. 6.f-$..r_, !.,� f - . �-••------------- FEE........................
�i��tt�ttl �xlt� C��tt��r�tr�i�it rrmif
Permission is hereby granted----- i_ _ -`�ti"= `��G -4-----------------------------------••------------------•-•-•---••--------
to Construct ( ) or Repair ( G)an Individual Sewage Disposal System
atNo.................................................................
asStreet
shown on the application for Disposal Works Construction Permit No--------------------- Dated..........................................
"'� ----------------------- --------------------------------------
�,. / el oard of Health I
DATE ---- ------------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r
I�
I
A
- -�