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0021 COTTONWOOD LANE - Health
`ill Cottonwood Lane Centerville A = 252 160 r �//p�p� RECY�LfpC n"'''«`^'p 2J� p2m UPC 12543 HAS71M09,(�iN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. When filling A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key I to move your cursor-do not DOUGLAS A BROWN c use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code � 508-420-4534 S 14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �4:.- 4/30/12 Inspectot4 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. t5ins•09/08 Title 5 Official pe on Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: TANK NEEDS PUMPING , CHAMBERS WERE DRY AT TIME OF INSP, PIPE FROM D-BOX TO CHAMBERS GOES INTO CHAMBERS THROUGH RISER 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•osros 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 ` 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ 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. I. 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 ►sins•09/08 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 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *` This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•ogioa 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 ( 21 COTTON WOOD LN Property Address ROSS Owner Owners Name information is required for CENTE,RVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the. questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 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 ' 21 COTTON WOOD 0 L N Property Address ROSS Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. City/Town State Date of 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 the were not to as N/A) available no y ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09108 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 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND 2 500 GALLON CHAMBERS Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate required]inspection re P q ] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: 2010---140 2011----162 Sump pump? ❑ Yes ❑ No Last date of occupancy: 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: bins•09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments GM , yi 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 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/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �t 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is CENTERVILLE required for MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: S.A.S WAS INSTALLED IN 2002 OFF AS-BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene t ass pol y ylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: HEAVY t5ins•09/08 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 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness THICK 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? I Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK IS IN NEED OF PUMPING i� Grease Trap(locate on site plan): , Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is CENTERVILLE required for MA 02632 4/30/12 every page. Cdyrrown 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 El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 - Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL SOME SOLID CARRY OVER Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,.•' 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name required for is CENTERVILLE required for MA 02632 4/30/12 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 500 GALLON ❑ 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.): CHAMBERS WERE DRY AT TIME OF INSPECTION WITH NO SIGNS OF HYDRAULIC FAILURE / 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•09108 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 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 COTTON WOOD LN Property Address ROSS Owner Owners Name information is required for CENTERVILLE MA 02632 4/30/12 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is required for CENTERVILLE MA 02632 4/30/12 every page. City/Town 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: 5.05 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: OFF PREVIOUS INSP REPORT BY ECO-TECH Before filing this Inspection Report, please see Report Completeness Checklist ton next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 COTTON WOOD LN Property Address ROSS Owner Owner's Name information is CENTERVILLE j required for MA 02632 4/30/12 every page. CRy/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION Z-I CDT I GJ00 0 LN SEWAGE # VILLAGE ASSESSOR'S MAP & LOT a (6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY (Dd LEACHING FACILITY: (type) q4llerl (size) �4�` Z��2 .f Z / NO. OF BEDROOMS ` BUILDER OR OWNER PrJ;4 q Gi�hSc'r�ut'$ PERMIT DATE: COMPLIANCE/DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility s ©5 1' 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 ECO Tec t _J � J LOCATIONS _ Zo o-aox a o/ r A B I 34 It 26 It SEP Tic 2 44 It 39 It TANK I B EXISTING DWELLING # 21 J NOT TO SCALE COTTONWOOD LANE i r -�v �� � �'��,CzC�� r� ,� �k _ � _f `� A Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification (% Important: When filling out 1. Property Information: forms on the computer, use 21 Cottonwood Lane - Centerville MA ` only the tab key Property Address to move your John and Alicia Gonsalves cursor-do not Owner's Name use the return key. 21 Beechwood Road Owner's Address VQ Centerville MA 02632 City/Town State Zip Code (RPMJune, 18, 2005 Date of Inspection: Date 2. Inspector: David D. Coughanowr, R.S. Name of Inspector Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther Evaluation//be�y the Local Approving Authority /C--� June, 18, 2005 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. t5-2090.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 , Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'G^M A. Certification (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: t5-2090.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM A. Certification (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced. ❑ obstruction is removed ND Explain: 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 t5-2090.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t5-2090.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5-2090.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM A. Certification (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2090.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form iG�M SV6�`e B. Checklist 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Check if the following have been done. You must indicate "yes" or"no" as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] t5-2090.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM C. System Information 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 2 Does residence have a garbage grinder? Removal of grinder is recommended ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 196 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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: Last date of occupancy/use: Date Other(describe): t5-2090.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form C. System Information (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection 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/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 2+years. Certificate of compliance issued 8120102 (Board of Health permit#2002-356) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2090.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System P Y Page 9 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM C. System Information (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): Depth below grade: 1feet 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 ❑ Yes ❑ No certificate) Dimensions: 8.5ftx5ftx5ft(1000gallon) Sludge depth: 8 inches Distance from top of sludge to bottom of outlet tee or baffle 26 inches Scum thickness 6 inch Distance from top of scum to top of outlet tee or baffle 6 inches Distance from bottom of scum to bottom of outlet tee or baffle 12 inches How were dimensions determined? Probe to top of tank t5-2090.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG M SV a Subsurface Sewage Disposal System Form C. System Information (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): A complete pumping and cleaning of the tank is recommended at this time and maintenance pumping is recommended every two years. Tank and tees appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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.): 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): t5-2090.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form aX Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4M C. System Information (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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.): D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2090.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments rG^M Subsurface Sewage Disposal System Form C. System Information (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Water was observed to flow out of the distribution box in an unobstructed manner. t5-2090.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form C. System Information (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5-2090.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LOCATIONS A B 20 D-BOX 0 1 34 ft 26 Ft 2 44 ft 39 ft SEPTIC a TANK o B A EXISTING DWELLING # 21 W I Z J � I W Q 3 I COTTONWOOD LANE NOT TO SCALE t5-2090.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 • ' Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form '4M C. System Information (cont.) 21 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code John and Alicia Gonsalves June, 18, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 5+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: 8/16/02 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: Approved design plan on file with the Board of Health shows bottom of system to be 5.05 feet above the bottom of a test pit in which no water or groundwater mottling was encountered. t5-2090.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 16 of 16 � i TOWN OF BARNSTABLE LOC A`1.10N ZI C01 fi D Q WOOD LN SEWAGE # VILLAGE CE Q T t AV i LJ- ASSESSOR'S MAP & LOT.A��(D6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) g+tter`/ (size) �A� 1 2'LI t Z / NO. OF BEDROOMS .BUILDER OR OWNER k1 41'Y Ct)hSgly 'S PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility + Feet Private Water Supply Well and Leaching Facility (If any wells exist on.site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by FCO - TBC- n , J N i #� o m z z *x m� — rz QWATER LINE 8 � z ,f m ' N- r 0 - � f U' Z n L4 f V m �OQO7 w I � - i I TOWN OF BARNSTABLE a LOCATION _2I Cr.flOGJ(�JCY---� Q (VI hlC-- SEWAGE # 3662-3S1 ,VILLAGE CjajN�F L (I�— ASSESSOR'S MAP & LO INSTALLER'S NAME&PHONE NO. (Z2!,6 t,,5S6W SEPTIC TANK CAPACITY C .600 LEACHING FACILITY: (type) 0 9YGJE-d S (size) P X(3)c a�f NO. OF BEDROOMS 3 BUILDER OR OWNER On- AIn) PERMIT DATE: S If 42 16 9- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Futnished by .-,. ,. .,- -- �1 � f c - �. i �� � �� i ,� f i �� / h � ___t. 4 w• No.....�s.� b i� ; FEE.....�1 .......... THE COMMONWEALTH.OF MASSACHUSETTS IrIl1tr BOAR® OF HEALTH PARCEL • �� Appliration for Displas al 10urkii Tnmunrtinn rrmi$ . Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal System at: 'W_.I MC. do - ddress or t No. ....... E#c _._._ ,_..... `' .............................. ---------------------11i"ej_"_.... ...... &J P? Owner � Add ss gg ,.a ---------------------- Installer Address S f d Type of Building Size Lot________ ________________ q. Dwelling—No. of Bedrooms______ ____ ____________________________Expansion Attic (a/j Gar age Grinder Other—Type of Building ._./5114_______________ No. of persons............................ Showers ( ) — Cafeteria ( ) p" Oth_er fixtures .........________________________ Design Flow____���_________________________________gallons per person per day. Total daily flow__.__ .____.________.________ Ions. WSeptic Tank—Liquid capa 'ty�0�.__._gallons Length. 'b t�_ Width___._��®.._ Diameter_ / ____. Depth8....... x Disposal Trench—No._/� _ ___. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._.___./____-______ Diameter....i�_.......... Depth below inlet...... ........... Total leaching area__ZQe_!....sq. ft. Z Other Distribution box (k) Dosing tank ) ®��� ••-----•-------•-•---------___ Date__._..-��. . Percolation Test Results Performed by-_-_��_ __ ________________________ _._._..._.__-. a Test Pit No. 1__.4 2—____minutes per inch De th of Test Pit---1W........ Depth to ground water__/A_E_�`_...... ._- fi Test Pit No. 2.... ._minutes per inch Depth of Test Pit...C3°__._______ Depth to ground water___.__�_ ............. • _------ ....................... O Description of Soil-----8' (_,.! !tSv ��L... `f '.---��°� �5J pi4_ 1 !u�� 1 fcr'4 -----•------------------------- ; - �I---FGtJ�- �� 1Esf�T 1L>PD/_emu. >Q49 -� � -•----------•--••••....•---------- U Nature of Repairs or Alterations—Answer when applicable............................ _-____G - ................................ ...----------------••-•--•--------------------------••-••---------------------•----._...._._._.._..--•---•-••-----------••••----•-•------•----------------••••--------- ............................... Agre nt h undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with t pr ass' ns TIME 5 of the State Sanitary Code— The undersigned further agrees not to place the system in ope i until fi f Compliance has been issue by the board of health. 6S'gCd•------•- C ""' ----•-----•-•-•-_--•_- ation Approved By---••---- ------ -----• -• -- ......................................... .................t�-' te PPlieation Disapproved for t e following reasons--------------------------------------------------------•-----------------------•-----------•--•-•--------------- ---------------------------•-•---•---------------••----•-•------••----•---------------------------------- -•-•---•------------------------••--- -------------- Date PermitNo........................................................... Issued....................................................... Date No.....?.:b6 Fx$....SID........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ..........OF......... .................................... Appliration for Disposal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct K) or Repair an Individual Sewage Disposal System at: .............. ILANE....1COMPNIJE.....................................tcT........1..7.3..................... o Add or Lot No. k -.:i� ------------------------------- ... ------------- . .........oe r- ........I_ ner AddEress.., ... ........ .......... .... ......... A.je ........................................ A r Installer Address Type of Building Size LotJ Sq f t U 'X_�-------------- * Dwelling—No. of Bedrooms... ....:...............................Expansion Attic Lf age Grinder A Other—Type of Building ... No. of persons.................:__.__.._._ Showers Cafeteria a 4( ---------------- Otherfixtures ......... ........................................................................................................................................... Design Flow....:� .................................gallons per person per day. Total daily flow-___-7��U .......................gadlons. 9 Septic Tank—Liquid ca ait�00......gallons LengthZ.-k...... Widthy�'i........ Diametei!�/p------- Depth5:1'6_11.... Disposal Trench /V No. ........... Width.................... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No......I............ Diameter...4�, .......... Depth below inlet-----f............ Total leaching area..2_1�,..4�.....sq. ft. Z Other Distribution box (y, Dosing Percolation Test Results Performed by_ ..1................................................. Date...... .......... .............. Test Pit No'. I--- 7ptc���of�j_.___.minutes minutes per inch 'P D Test Pit---/a .......... Depth to ground water-'IV .......... (ZA Test Pit No. 2...4JL.......minutes per inch Depth of Test Pit...13............ Depth to ground water-----jC) ............ .......................... ........................................................#_]M........ ------------*-------------,....................... 0 Description of Soil--- ...............................................f.-D- ±/�'_j.�_,Q1 ..................................... ........ U ----------------------*--------------------------- ...........7 .............. ........... 4(1" -/- --------------------------------------------. ------------------ ---------.--- U Nature of Repairs or Alterations—Answer when applicable..........................Z_:{7.... .................................. ........................................................................................................................................................................................................ Agre7mfnt- T T undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T— t 7ep v i 11 A. T LL 5 of the State Sanitary Code— The undersigned further-agrees not to place the system in op ti until fi of Compliance has been issue by the board of health. —7 S ird........ ........................ --- -- --- - ----------- a /Date Ap ion Approved By........ ...... ............(�. .... . . .__.j -------*.....*---------- ----------- &�Ilpplication Disapproved for h following reasons:............................................................................................................... k� ........................................................................................................................................................................................................ Date PermitNo................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF.....'?9K111F1 ........................................ %funfifirate of Tomphatta THIS T,JS 0 CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.. .......B.!.......0�K------------------------------------------------------------------------------------------------------------------------------------------- Installer / 7................. OVI._jK V at..../-0.7--__-/X��.......... . ............................... has been instilled in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated___..______.__._.......____._____............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C NSTRUED AS E SYSTEM WILL FUINCTIQN SATISFACTORY. NSTRUED A4 A V7UIA)L�NTEEAHAT TH DATE.................. U............................... Inspector...... ....... ............ ........... ....... ............I.... THE COMMONWEALTH OF MASSA USETTS_S'�' \j BOARD OF HEALTH V ........................................... 0 7. .................OF....... No......................... FEE........................ Permission is hereby granted...Al&r...... ................................. ........................................................ to Construct or Repair an Individual �ewage Disposal System 0 Y, C_.. .......... at No/.eZ�.......... .7. .......... �d........C-4/,r d........................... .......... ...............(� Street as shown on the application for Disposal Works Construction Permit No.............. .... Dated....60.. .......... ................................... ------- -------------------- '- G o h DATE...................J��.................................................. FORM 1255 A. M. SULKIN, INC., BOSTON V L ('LOCXTION 2� SEWAGE PERMIT N0. Z"TZ73vyu VILLAGE INST ER'S NAME&ADDRESS yu 0-t BUILgER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r; t �y� . 3�, , � �� r = ``N OF Mqs FdBso ERT.. / s o ELDpEDGE If 3x* 9 No., 19307 0 l C.: sErv/c�GGNiY' 1t '�ECISTE�``�J � 0: �r' #;F ' S�24AL'IAMB C7 L-v T l 73. � ;. �- �" Q. _ Pf?2 TF?t-E K 1 /XZ, Al ILI— C x a „�t IvpT!rw ' t$SSu i►t�D �/ 1 � F� I 0 `,>< Ala i v'7"c c-r� nJ nE� -r, , 0 t rry Tu/ry TjY�A v✓S�. � � �✓� :',MA / V n �xs S.- 4 _ 9!. r / xta 4,4 '''�� `�'�- r, � '_' �: % ! �� 'f,e,)f�' ./, `J Ill �• S-49_ % iG n�C N'i .}} o o ERT 9C2A/ WO ' 4. i ;7 s NiURSE 43. } N '10951 D 4 r kFSlONAL� LEGEND AX18TIN9 9POT ELEVATION 0O EXI9TINa :'CONTOUR --- 0 ---� CERTIFIED PLOT PLAN r71INISNED 9POT ELEVATION F'ily.i9.MEQ >'CONTOUR 0 LoT 173 CorTdNw,90,0 �.44 NOTE The aocation of any existing- underround sewerage, dwells, _ other :utilities shown .on this plan is approx- IN i as'- determined'only' a - determined from records..and/gr verbal \ nfoxmation:.;The contractor is responsible .forYthe SA red��S-TASI L �.�,u�� � � vgr�fcation-of the .existing locations in�,the field. SCALES "=30� : DATES t .�-DR--EDGE ENGINEERING CO LINO /'1 G�����✓ P ,,.x ,,.''1�... ,�...--.... ... 1 . CERTIFY THAT THE PROPOSED1 E4ISTERE REGISTERED JOB N0. ';y b¢ BUILDING SHOWN `ON THIS PLAN LAND R e .LAWS VCONFORMS TO THE . ZONIN OF .BARNST MASS'DR.BY, A' .ER ` V ' } =712 MAIN $TREETu - CH.`BY� 13.E Y S . MASS Z f, 4, SHEET..:L OF TE REG. . LAND SURVEYOR 'h ": % S.• .. x Kt - - 4 '3.Jt}� ,..... :. Y'"�;< ., ti '! �r„y✓'w. ��. 9•R• " ,alt'..y,,;y�:{h y.�..x y.:. •'�'.i'h:'y .y d . -,:- ^+?, � ..au :.n �. -�-c"• -sa..w: x- :.{ . _ .. . ;t,�: �..� -s-. +� ,-.,.�:, ,�.; .��,:..'� ,.+ • -• '-c.. .. pp-i-r> ';� ^•h' +. :,.e ,yv�,�. A••,.' 'S,�v:. '�. n -�,7 "•_b`...`5'` .., �wg{zrv. 'i. -,r,: ,,.�.a ,; .t.- ,ate :R-.s.. .a,.. d,. -� -.CN,.� ...ga ,.h�.;az�:f� .,., Tr.t<6 '-'-�',.:r:, sc ,tA .yyv4 ,.es e'l'« :'yr! 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O/STR/6!?/ON BOXIONf GROUND,i4ITEX TiIQLE �lJT1ET0!STR/BIT/ONBAX f7 `IYLE?r LEIICX lN& P/T 1s/- 'FT SEN/AGE- .S/�05A L SYSTEM 7�40g/jATIDN LEACHI"Cr n MExsio/V Ad fT D.ESI SM CAI TERM KALE . .�4 r.: /• 0' Al NU.►!t'JER OF.BEDROOMS .� 3 � •D/MEJKS/ON - G�_�.f T�/i✓, . v• LOGG•ReA6,FoiSR05AL.4ly7 � SOIL. s SO/L TEST 7-ii i7 IL .E,?T/M.�TED FLOW 330. `G.4L. DAY SO/L TEST /. 30./L TEST P 4(UMaE*, G,e XJwACAfI;VS P/T,S / FLEY. 4Z 1~EL Y. ?LZ A7E 0A JO/L TEST 90T'TOM."LFr�CNlNG PL'R P/T U Yz b LESS /NCN 7 fr ::SQ• Lo sF M mac., PE/t COCAT/ON.RATE �—OTAL"LEACH/NG AREAfT 5 t/(i gar+ b.- Su/3 so�4 AIcPCCOLI�T/ON RATE 2 MI7V�/NCH RESERVE 1-4S44rN1N6 AR,-A 'z G 6'S4. F T �1 ;5/',-r,•';G y� :t. . . -" ENE ~. IH.flF.Mq �L gL7., awst�o_%�rL� ;� 7�' �'vT .'/ 73 CUT:T Of: v7J 7idDOD E�`ZN gB/'+E SrLt T P J p ROBERT_ yG $' ALBERT G cZr / sip 4 13•: A —+ p- - 4 - ELDREDGE L3. MORSE _ JIVG- c Nr NO ':1936T Q4 No..iD95 a ' �d4r EL� � ° <,.�.; w`- , ., ...,:::- r- :•.o G ,� ,. T-.a s .,, `o «�e .z s ti;:. ..Dm.: 7fz .aDe�E�./ E�..`,w ,,�,� € -: 2F � �. �' J 3 �E .`�6.�' M ri:�� � �,� � O ,� �',t'°41 ��r7�t+.. •:..a a 5,. <n'� 4,. �•��„s r{ r: 4• �.: °„F•�F .., �`�L�t.f►ND.- ,�.. � << �, ;I/ //. ..: _.,K.,�•�. :;G�LO,tJI1lD L✓ATE� wr�L;es! ..�:._.�. � O10 ::.:r<b:�` � .. :: rn.. ,; .-�+��z r-;;.. .A-..•: .,r.. .f• 3' � Ya { .«�.�t;`<� ��; ".i ,a :.x ,,..t: ;,, .: -.-' i 'a �..,�r § .:.•Y,�"+'t ..-. v--..,xy S^ ;xq.:e ,,,:.7'r.-,F z:,.�:q,.,., b,'�d'. 3� � s,.r.w. _`Y'.ca+'d w.r:'t: ,„„ �k, .:r�..,..�� ,AID. n ,.,.�,;,.<:d-}Kq,y ,....-. �„�.. ,t.,- �s r •4;:. ,.. 1�j5 ..4 t"�. •.s - .�- :A., ,�,_,a,.,,.w ��_,, � _ �+q„ .sE'.s' .: Y :k.;t� s,".-�.,.d,:>..+Y_�. .a.,.a,€ ., ...*a., ,. ,.. ''�*'.. ....�.. "+...F .a, .:;'€ z. ,.�. .+ k ��r sn "..r^ <YS; ri xLM r+- rs •`S•$ t ..'as,�..a 4:2�..ay'ads-�uri�t.T�„±rztt'.s.�.. ' 0, f - - ( ofI)P1t.,ted by s , HlCH GROU►D7WA1l R LEVEL C0MPLHAT'IOtt y «S r to Locat ion Lot. _,. _.. --- �_-- — 7-.___ Owner• Address:. Cont-i actor: Address. STEP 1 Measure depth to water table t to nearest 1/10 ft'. . . . . • _ J date }* STEP:: 2 Using Water-Level Range Zone and Index Well Map locate site and dete-rmine: Z-j A) Appropriate index well Z B) Water level range zone . . . . . . - STEP_; 3 . Using monthly report"Current Water-. Resources Condition ''_' determine current depth t 2%z - ~ •:::` water level for index .well ` 8S y/ mo yr „ STEP :Using Table of Water-level Adjustments for .index well STEP 2A current depth to ------ A , water level for index well (STEP 3) , and water-level --- zone (STEP 2B) determine I- �- ,,. water-level adjustment . . rj Y STEP 5 Est,inate depth to high water E by subtracting the water- level adjustment (STEP 4). £r y from measured depth .to water level at site (STEP 1 ) oFtMETo� TOWN OF BARNSTABLE OFFICE OF Bsa Mug t BOARD OF HEALTH � AlH. � i639 367 MAIN STREET HYANNIS, MASS. 02601 June 20, 1985 I Mr. John C. McKeon, Jr. President McKeon Custom Design, Inc. 1645 Rte. 28, Bayberry Square Centerville, MA. 02632 Re: Lot 173, Cottonwood Lane, Centerville Dear Mr. Keon: You are granted a variance from the Interim Board of Health Regulation requiring one acre lots for sewage flows of 330 gallons. The variance is for Lot 173, Cottonwood Lane, Centerville. You will be required to meet the following conditions: (1) The designing engineer must be on site to supervise the removal of the unsuitable material and the installation of the on-site sewage system. He must certify, in writing, to the Board that his design has been complied with prior to issuance of a Certificate of Compliance and Occupancy Permit. (2) Water saving devices must be installed on all fixtures.- This variance expires July 1, 1986. This variance was granted as the subdivision is fully developed with the exception of this one lot. It was the opinion of the Board that the granting of this variance would not contribute significantly to the ground water problems or the environment: qe truly yogirt Childs Chairman i BOARD OF HEALTH TOWN OF BARNSTABLE JMK/mm President: Member df: ROBERT BRUCE ELDREDGE,R.L.S. a CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS ELDREDGE ENGINEERING MASS.ASSOC.OF LAND SURVEYORS Associates: AND CIVIL ENGINEERS ALBERT A.AQORSE,P.E.,R.L.S. COMPANY, INC. AMERICAN CONGRESS ON PHILIP WEINBERG,P.E.,R.L.S. SURVEYING AND MAPPING Q �7 AMERICAN SOCIETY FOR GREC�CSEE2E� <1. GJ\EC�l1 tE2E� TESTING AND MATERIALS �anc� �tvl� 712 MAIN STREET GJtt4VEt�041 k, 3 E-9inevu HYANNIS,MASS.02601 TEL.(617)775-2244 July 10, 1985 Board of Health Town of Barnstable.-- 367 Main Street RE: 173. Cottonwood Lane Hyannis, Massachusetts 02601 Centerville, Ma. Gentlemen: An inspection of the 32 foot diameter excavation was made on June 17`;. 1985 and an as-built inspection on July 10, 1985. The foundation for a two car garage has been added on the right side of the house foundation, (which is essentially in the same location as shown on the proposed plot plan). The pit is about 18.5 feet from the garage footing (no basement) but is still well over twenty feet from the "basement wall" as required by the Title V State Sanitary Code. In conclusion, it is my opinion that the sewerage system,has been installed substantially in compliance with the proposed sewerage plans dated June 4, 1985 drawn by Eldredge Engineering Company, Inc. Sincerely, ELDREDGE ENGINEERING CO'. INC. r Robert B: Eldredge, R. L. S. President cc: McKeon Custom Design RBE/etb II