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HomeMy WebLinkAbout0131 ABBEY GATE - Health (L Abbey Gate P ' 4 \1 fl I f� i, i i �l ,t TOWN OF BARNSTABLE LOCATION /,V 461eV ,C&a- SEWAGE# 0-20- a 9'1 VILLAGE (& r-1 ASSESSOR'S MAP&PARCEL W( -.OZ INSTALLER'S NAME&PHONE NO.;O, 13,�k) �C SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS Ad/,�' OWNER PERMIT DATE: ?;,, �3 COMPLIANCE DATE: 1 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� A L hblv7, il A x,x)ef co.A,,cckd' z3 G yz 8 reef lithe ff;,v44,.J4, it Pr;AN*ry Al -e �,� No. Q o' Fee J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es 01pplitatlon for OispoSal *pstrm ConstrUttion Permit Application for a Permit to Construct( ) Repair('') Upgrade( ) Abandon( ) ❑Complete System 'ff I, ndividual Components Location Address or Lot No.131 A" &a" Owner's Name,Address,and Tel.No. Assessor's Map/Parcel CtV gY 2L Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 F Lot Size sq.ft. Garbage Grinder( ) Other Type of Building � No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re uired) 2 3 U gpd Design flow provided 3( V gpd Plan Date o ' U Number of sheets Revision Date Title Size of Septic Tank 1jud x k-_)h�n Type of S.A.S. G an cll� Description of Soil Nature of Repairs orAlterations(Answer when applicable) QR&0, \jcW n� C XK16� s 06%S CniC J K) SCAM AJ as, PerirnNnto ✓� ,L1,`Npa f (JP`PC� Date last inspected:Agreement: ArOV711 U,rf —ovx co'-J r at ,,v�(opt'1, I� 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. gion Date Application Approved by Date -7 J° '2°�°' Application Disapproved by Date for the following reasons Permit No. ad Xo r Date Issued J° �K� ------------- f/ ta.. ti, K7`,yM[ SAL No. ,'` 't ' Fee u� y THE COMMONWEALTH OF MASSACHUSETTS Entered;ncomputer: - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS res y ZIppiitation for MispusaY 6pstem Construction j3ermit Application for a Permit to Construct{`) Repair )''Upgrade( ) Abandon( ) ❑Complete System `r Individual Components Location Address or Lot No.. } f� ta+'P Owner's Name,Address,and Tel.No. " F Assessor's Map/Parcel V _ Installer's Name,Address,and Tel.No. Designer's Naxne,.,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) l Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re uirefd) t:P gpd Design flow provided 7 gpd Plan Date r 1 a!' Number of sheets Revision Date `a Title d Size of Septic Tank I)UJ Type of S.A.S. '' Description of Soil Nature of Repairs or Alterations(Answer when•applicable) 1 p� &XISbW -'SAS -.4m ) Cf6�1�C! 1C Date last inspected: d' r #- Agreement: / s.'®► dic oq,.J r n !?.N b(P 41. i 1/ , P } The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in - `r 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. Silne tsr' CW _ µ Date 7-2 2-?9-20 .� 'Application Approved by yl,�f � �' Date �".J?°' � •+ � . Application Disapproved by s Date *. for the following reasons - Permit No. ad �-o 0jLt/ Date Issued '3'�' C7,2 C. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( )_ Repaired( Upgraded( ) Abandoned( )by `A x4 f"t,,s 3 rx N at 131 A 1r1lop/ Car Cory it- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. o >,���° // daated %''3o Installer, dam, A ,�� TitiC- Designer ,.`�.�J A l A r)o^) #bedrooms Approved design flow �� � .�� gpd The issuance of this permit shall not be construed as a guarantee that the system will unction as designed 6/ . Date l i/2• Inspector lli "t/ 1'—j , _ I - --- ------------------- ------------------- Fee THE COMMONWEALTH OF MASSACHUSETTS (PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Mispo8al *pstem onstructlon permit Permission is hereby granted to,Construct air Upgrade struct Re U f ( ) P ( ) pgr Abandon ( ) ( ) .` System located at 114'Abbia., 60+e (y1-(j Ii- 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:Construction must be completed within three years of the date of this permit. ' _ "� Date ' �D Approved by oa Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves ,_ Owner Owners Name f i A information is required for Cotuit V MA 02635 8/15/18 4X. , every page. Cityrrown State Zip Code Date of Inspection yr 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. A. Inspector Information 6 /3 ,2Z � Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 I 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 8/15/18 Inspector's nat Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owner's Name information is required for Cotuit MA 02635 8/15/18 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owners Name information is required for Cotuit MA 02635 8/15/18 every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or.obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: " ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owners Name information is required for Cotuit MA 02635 8/15/18 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address, Ginouves Owner Owner's Name information is required for Cotuit MA 02635 8/15/18 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r/ f� 131 Abbey Gate Rd. Property Address Ginouves Owner Owner's Name information is required for Cotuit MA 02635 8/15/18 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owner's Name information is required for Cotuit MA 02635 8/15/18 every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner information is Owner's Name required for Cotuit MA 02635 8/15/18 every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owners Name information is required for Cotuit MA 02635 8/15/18 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from-system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date.installed (if known)and source of information: Existing septic tank and new D-Box and leach chambers 2010 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Line sleeved per BOH record feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 16 c Commonwealth of Massachusetts Title 5 Official Inspection Form ! 1. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owners Name information is required for Cotuit MA 02635 8/15/18 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound j i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 1/2' >2„ Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owner's Name information is required for Cotuit MA 02635 8/15/18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction:, ❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owners Name information is required for Cotuit MA 02635 8/15/18 every page. Citylrown 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 011 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.): H-20 box 2'6" below grade , cover raised to 18", no adverse conditions t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner information is Owner's Name required for Cotuit MA 02635 8/15/18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: , Type: ❑ leaching pits number: 2 ® leaching chambers number: ❑ leaching galleries number: ❑ Teaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form (. Subsurface Sewage Disposal Systems Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address + Ginouves Owner Owner's Name information is required for Cotuit MA 02635 8115/18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers were video inspected and are damp at this time, no indication of past hydraulic failure, soils are compact and dry, bottom approximately 5' below grade 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction 4 Indication of groundwater-inflow ❑ Yes No Comments (note condition of soil,.signs of hydraulic failure,level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owner s Name information is required for Cotuit MA 02635 8/15/18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owners Name information is required for Cotuit MA 02635 8/15/18 every page. Cityfrown 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 9 Z3 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owner's Name information is required for Cotuit MA 02635 8/15/18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet 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: NGW 120"2010 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4'seperation per 2010 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, sit is 16' msl and nearby wetland is 4' msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on.next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Abbey Gate Rd. Property Address Ginouves Owner Owner's Name information is required for Cotuit MA 02635 8/15/18 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 A PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipprtcatiou for Mi5p0ar 6p5tem Construction Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. � )A BtFY GAT'V OwsN mAddre Corv1 W �.�Wv Teb4)voJV,55 Assessor'sMap/ParcelYU��/Y!� Installer's Name,Address,and Tel.No."_�v���.� � Desi er's Name,Address and Tel.No. �—o K-a A-souu S� Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building ILI No.of Persons Showers Q) Cafeteria4..—) Other Fixtures &A Design Flow(min.required) gpd Design flow provided '3 !�'Q gpd Plan Date S-:,42 /,!�Z 2 Number of sheets Revision Date Title w .ram Size of Septic Tank L Type of S.A.S. 'J—�CA44o C v y AC Description of Soil � Nature of Repairs or Alterations(Answer1wen p licle 0F!f 7_e © v h C S OC/ P v� Date last inspected: Agreement: The undersigned agrees to ensure the construction and intenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm al Code and not to place the system in operation untilCicate of Compliance has been issued by this B ealth. Signed a Date Application Approved by Date Application Disapproved by: 41,ZDate for the following reasons or Permit No. e "�` Date Issued No. ; Fee �— ! THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 0� PUBLIC HEALTH DIVISION - TOWNIOF BARNSTABLE, MASSACHUSETTS. Yes . � ZIppYication for Dfo ogal !gtem Cow5truction Permit Y Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon,( ) ❑ Complete System ❑`Individual Components Location Address or Lot No. J )A'W Y 6,A rf Owner's Name,Address a d Te No. CGS CA '�if/o Assessor's Map/Parcel s� j 3/ �G�W�7 Installer's Name,Address,and Tel.No Or ��.SCi�✓'�/� Desi er's Name,Address and �23v�1I lr � c .,,,, and Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder"(---�- t Other Type of Building No.of Persons a Showers(,`�) Cafeteria. -.-) Other Fixtures _A 1A 10/ Design Flow(min.required) 73 3 O gpd Design flow provided gpd Plan Date S'�o`? /�„�a/� Num-b/er`of sheets Revision Date Title �� aStz=GUiA 6F �•c.6�/ "; Size of Septic Tank / / 6- om Type of S.A.S. ',r0V CA s C p,(J C1,4A PEX_t> W -9 Description of Soil Nature of Repairs or Alterations(Answer1wena p licab e) D1�L F7_E" ,� Y"A. 6&_ -5 TI o vC� lot, L 6 e a Du Cx? 5'GY 7kn An a s 1 t(� / ' jz p e r Date last inspected. ' Agreement:The undersigned agrees to ensure the construction and intenance of the afore described on-site sewage disposal system in f accordance with the provisions of Title 5 of the Environme .fal Code and not to place the system in operation until a Certificate of - Compliance has been issued'by MthisBod O ealth. Signed �� Date S Q� D t Application Approved by ` f J Date r J• cry # 'r Application Disapproved by: Date t . s for the following reasons I � $ Permit No. "` Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,/MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constru ted ( ) Repaired ( ) Upgraded ( ) Abandoned( by at P # )� has been constructed in accordance with the provisions of Title 5 a the for Disposal System Construction Permit No. / dated Installer Designer ll #bedrooms Approved design flow t! gpd The issuance of t s pe 't shall not be construed as a guarantee that the system Wfl 7fue ion as desi ed. Date h Inspector ---- -------.--- -------- --- ..-----.-----._---- ---- No. t / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS lwigozar �&pftem Construction Permit Permission is hereby ranted to Co struct�( Repair ( Upgrade ( ) abandon ( ) System located at �� j ro and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Cons)tuctionpiust be completed within three years of the date of this ermr. ) Date / Y Approved by ,+ 1 TOWN OF BARNSTABLE LG-( ATI0N �% !� 2?3-9- SEWAGE# pi0/Q' 'O /�t� v � C ILLAGE � ASSESSOR'S MAP&PARCEL 047I O�� INSTALLERS NAME&PHONE NO. Zedl'el;r, SEPTIC TANK CAPACITY p i LEACHING FACILITY.(type) - ®.j W6ALLa, ize) 13 NO.OF BEDROOMS 13 ( 1i—ad ✓G IS® ) OWNER L �csS+�C� %N ut✓E PERMIT DATE: 5�6ZRO/0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 40A Feet Private Water Supply Well and Leaching Facility(If any wells exist 9 . 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 �- 3 �o2i TOWN OF BARNSTABLE � t � �- `�'�-� SEWAGE # LOCA ITY - ll VILLAGE— ASSESSOR'S MAP &`I:OT ial INS'iALLER'S NAME&PHONE NO. _ SEPTIC TANK.CAPACITY 1 U 6 b LEACHING FACILITY: (type) ()t-Q t (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 well s exist `within 300 feet of leaching facility) Feet Furnished b �� G�ac.� r AC 3i �g 6o h oc O c 36 i -L.00A'TION � SEWAGE PERMIT NO• 12 VILLAGE INSTA LL-ER'S NAME A . :-AP-D-"RESS zv B U I L D E R OR OWNER 1 DATE PERMIT ISSUED , DAT E COMPLIANCE ISSUED - � `_�... ,e _ a. � d t, 4 ^, I7u�y'] f! IJ^! Q !. ` ��� e Town of Barnstable � y Regulatory Services Thomas F. Geiler,Director + BAjENSTi1BLE, AV a Public Health Division zFp a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 -Fax: 508-790-6304 Installer &Designer Certification Form Date: U 1 b Designer: �/�� �• N(�� tj..( Installer: O - �E1�elh�tllt1 Address: . Address: OnIrQa/62-xe was issued a peru :t to install a date) (installer) septic system at_*I?J( based on a design drawn by address) ��� �• ''l� dated 016 / (designer) _ j••:certi that the septic system referenced above was installed fy p y d substantial ly according'to design, which may include ininoi approved changes such as lat..,4. relocation of the dj:s ibution box and/or septic tank.._ I certifyf'that the septic system:referenced above was insti& with. €a�or,changes greater thin 10' lateral relocataou of the SAS or-any verEical.".' titan of any comport t of the septic sys em)but in aEcordance with State&L6cARegiflat ons. flan revis oxk or, ce fied as-bit by designer to follow. . .�iti`o�Mgs� h Z� ID- (Installer's ignature) n LIASQN (D er s Si _ attire} "s Stain Here gn . (Affix P. PLEASE RETURN TO BA +TST�PUBLIC. HEALTH:DMSIOI .: RTI +'i[C TE OP'.. CONILE'LIANCE WILL :1V®T iE SSUED: BOTH'-THIS-iFQ- RM BUILT CARS ARE RE.CETt7ED B' f'SE:PARMTAIRLK PUBLIC XIFIDIVI If?I�T THANK,YOU: Q:Y�ealtih/SepticlDesib er Certifica ion'Fotm ` . ,, TOWN OF BARNSTABLE LO(:ATION '3J�Fy 6;4)71 SEWAGE# ,t1010 VILLAGE Cow%� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. 4) SEPTIC TANK CAPACITY LEACHING FACILITY:(type) - •`to a 60GALLO ChatsiZe) X y 74-, m NO.OF BEDROOMS 3 -.2d ql-b X OWNER L vf✓ /� Vu�E ` PERMIT DATE: S-�' � ���" 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 9 on site or within 200 feet of leaching facility) 4 4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY DEEP®BSERV I Depth from H®�' Holz? # P Soil horizon Soil Texture ` Surface(in.) Sdil Color Soil Other (USDA).. (Munsell) Moulin g (Structure,Stones';Boulders, Uj" Con istenc % ravel M %G , loin DREP OBSERVATION HOLE LOG Depth from Soil Horizon Hole # Surface(in.) Soil Texture Soil Color (USDA) Mat Other (Munsell) Mottling (Structure,Stones,Boulders Vrl e-tA Consis e c %Gravel) A7 . 415 Bey r � • zs x y DEIEl�®BSEHV.ATION HOLE L®G Depth from Soil Horizon H®le#' (USDA)Surface(in.) Soil Texture Soil Color �--- Soi l (Munsell) her Mottling (Structure, Boulders. Co siste c O vel 7- DE,lE P O] S i R Depth from VATION HOLE LOG d° Soil Horizon Hole# Soil Texture ' ,z} Surface(in.) (USDA) Soil Color Other ) S'oll (Munsell) Mottling (Structure,Slpnq,,Boulders, Consistengy,c a 1 h Flood Insurance Rate MR Above 500 year flood boundary No Yes Within 500 year boundary No Yes Within 100yearfloodboundary No _ yes Depth oT rNatu>ra11V OCC erring]Enei~vious material at least four feet of naturally occurring pervious area proposed for the soil absorp material exist in all areas observed throughout the tion system? If not, what is the depth of naturally occurring pervious matorial? 4 I certify that on �. �~ (date)I have passed the soil evaluator examination approved by the Department of Environmental.Protection`and that the above analygis was performed by me consistent with the req(tire d training, expertise and experience described in CIO CMR 15.017. Signature 4 '' � Date /�� ;6 Q:\SBPTICIPERCFORM.DOC Town ofBa' r s THE P � Depaa'kimCaat of Regulatory Services / Publicdeal th Division Date ASS 200 Main Street,Hyanuis MA 02601 7 �ApFD ,1 A Date Scheduled !� 2 TihleT. Fee Pd. /� 00 � Soil Suitability Asses,smentfor Seuo age isp salt (e Performed By: '�� Witnessed By: � + V`.i ��rr--++ �-r�,t��--��,�-p � tr �rtt,,r-�try�/ �+ �T � LOC TI® artRL 'IYJVl`(S�1L9 A Li 11N �J'Jl' K&A IO Location Address Iv � � -oL Owner's Name a 6-/✓iQ u.vu ' Address C /l Assessor's Map/Parcel: f'/a y Engineer's Namc � a VO t''—' e ` NEW CONSTRUCTION REPAIR Telephone If C Land Use Slopes(%) '� U Surface Stones ��/"�j� Distances from: Open Water Body�ft Possible Wet Area I u' ft Drinking Water Well A 11� :ft Drainage Way ' ft Property Line 149 ft Other ft t SIMTCH: (Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands'in pro)rintily to holes) N 4 , / VAN � E Parent materal(geologic) ��� Depth to Becboek Depth to Groundwater; Standing Water in Flole:/(I/l>/V _ Weeping 1'Iom Pit Nice /)/Qyu Estimated Seasonal High Groundwater lD]TEPIM VA'ICION FOR SEASONAL 111011 WATER TABLE Method Used: Depth Observed standing in obs.hole: la, Depth to 5911 INUItIO; In. Depth to weeping from side of obs.hole: Ill, Grumirlwuter Adf usIment o,�,,.�.,,..^I'r. Index Well# Reading Date: Index Well level T , A0_1,ftletor,- A4).Grtlunl WaW Level PERCOLATION TEST MIN Observation Holc t1 / Time fit 9" Death of Perc L -� � Time at 6" T f Start Pre-soak Time @ Time(9 -o ) End Prc-soak Rate Min./Incli Site Suitability Assessment: Site Passed SiI.q-Failed: _ Additional Testing Needed(YIN) Original: Public Health Division Obsm:anion Hote Data To Be Completed on Back----------- ***If percolaatiou test is to be conducted within 100' of Wedand, you must first aaotify Q.Nie. Barnstable Conservation Divisiola at➢east ogle (1) Wee➢c prior to begiaaaaiNg. \f:\S EPTIC\PERCPORM.DOC COMMONWEALTH OF MASSACHUSETTS Y�, EXECUTIVE'OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION F � f d ti a eW y0 ` tOM.. i. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FO _ RECEIVED PART A CERTIFICATION AUG 5' 2002 Property Address: 131 ABBEY GATE COTUIT,MA 02635 0-"1 O 2 A TOWN OFBARNSTABLE Owner's Name: GOULD HEALTH DEPT. Owner's Address: PO BOX 161 COTUIT MA 02635 Date of Inspection: 7/22/02 Name of Inspector: (please print) JOHN GRACI Company Name: 3 SEPTIC INSPECTIONS 1 e Mailing Address: 111 P.D..B;OX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 s o'f the time of the inspection.The inspection was performed based on my training and experience in the proper function a'h&mamtenance 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: X Passes''I' t _ CoIF , es _ Neluation by the Local Approving Authority Fa Inspector's Signature: 3Date: 7/22/02 The system inspector shall suhis inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inystem 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 or should be sent to the system owner and copies sent tort e buyer, if applicable,and the approving authority. Notes and Comments i ;r SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY YEAR TO PROLONG THE SYSTEM'S USEVUL LIFE. ****'Phis report only describesleo�ndilions at the time of inspection and under the conditions of list at (Jill( (in►c.This inspection does not address how,the,system will perform in the future under the same or different conditions of use. •�rf to•. rn Title 5 lncnPrtinn Fnrm till V)fl)0l 0 1 Page 2 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 131 ABBEY GATE COTUIT,MA 02635 Owner: GOULD Date of Inspection: 7/22/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: �- a,, X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN EVERY YEAR TO PROLONG THE SYSTEM'S USEFUL LIFE. v 1.. B. System Conditionally Passes: _ One or more system compo•,pe0tsas'described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacemen�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. n/a 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: n/a n/a Observation of sewage backup or breakout 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 _aobste-uction is removed _ distribution box is leveled or replaced ND explain: n/a s='' n/a The system required pumping more*thanA times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of fHe'A6Ard of Wealth): w _broken pipe(s)are replaced _obs'tr ction,is removed y zn '' r ND explain: n/a '`` Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 131-ABBEY GATE COTUIT,MA 02635 Owner: GOULD Date of Inspection: 7/22/02 i 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,BRoard of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a mann" which will protect public health,safety and the environment: _ Cesspool or privy is within S0,feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh a` t, 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: r. _ 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 I 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 t' land SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Metho'd'dsed,to determine distance n/a ' . "This system passes if thi6Mell water'analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compound§'.'indicate's that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogenyis 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: n/a , C l Page 4 of I I "= OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 131 ABBEY GATE COTUIT,MA 02635 Owner: GOULD Date of Inspection: 7/22/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to e'ach of the following for all-inspections: Yes No _ X Backup of sewage'into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent,to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow X Required pumping''more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NO PUMPING INFORMATION, X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cessp`oo'Itor,.privy`is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or,privy is within a Zone I of a public well. X Any portion of a cesspool or'privy is within 50 feet of a private water supply well. X 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,'fo'r 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 thai 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'Mils. 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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply' 'to large sysfem`s in addition to the criteria above) yes no ,V` X the system is within 400 feet of a surface drinking water supply X the system is within 200"feet`6f a tributary to a surface drinking water supply _ X the system is located-it a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public.water'supplywell If you have answered"-.yes"to any3question in Section E the system is considered a significant threat,or answered "ves" in Section D above the large's'ysiem'has failed. The owner or operator of any large system considered a significant threat under Section L or failed under 5eclio6b shall upgrade the system in accordance with 310 C;MR 15.304. The system owner should contact the appropriate`iegiohal office of the Department. rC: A Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST i Property Address: 0I ABBEY GATE COTUIT,' MA 02635`'` Owner: GOULD , Date of Inspection: 7/22/62 _4} Check if the following have been done'You must indicate"yes"or"no" as to each of the following: s . Yes No t X _ Pumping information'•was provid'e'd by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received`normal flows in the previous two week period ? X Have large volumes ofwater been, introduced to the system recently or as part of this inspection ? X _ Were as built plans'of.the system'obtained and examined?(if they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? 4,. X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? h X _ 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 ? X _ Was the facility o%>►er(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal-systems?,'' The size and location of the Soil.Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.'For'example,a plan at the Board of Health. X _ Determined in the field`(i`f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] i . t Page 6 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 131 ABBEY GATE COTUIT,MA 02635 Owner: GOULD Date of Inspection: 7/22/0i, FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):..3, `Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR I;5.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage g`ki'der(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no)l NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):.Ra(DC) e Sump pump(yes or no): NO l `(D oo Last date of occupancy: n/a COMMERCIALANDUSTRIAL ` Type of establishment: n/a '+ Design flow(based on 310 CMR 15'203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no):,NO , Industrial waste holding tank present'(yes or no): NO Non-sanitary waste discharged'to the Title.5 system(yes or no): NO Water meter readings, if available::n/a Last date of occupancy/use: d/a OTHER(describe): n/a ''`' GENERAL INFORMATION Pumping Records 1 Source of information: NO PUMPING INFORMATION Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons`-t;How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all componeritsi date installed(if known)and source of information: 1983 BY OWNER n, 4 '. Were sewage odors detected when.arrivirig at the site(yes or no): NO dr A Page 7 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131 ABBEY GATE COTUIT,MA 02635 Owner: GOULD Date of Inspection: 7/22/02 BUILDING SEWER(locate on site plan)` Depth below grade:22" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance from private water'supply`well br suction line: n/a Comments(on condition of joints,venting,evidence of leakage, etc.): TOWN WATER > 4 SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete 'metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is ag&onfirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8'6" H 5,;7'I.WW 4' 10"" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum`7~o bottom of outlet tee or baffle: 14" 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.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING N`OV1'AND THEN EVERY YEAR TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concr'e`te' metal_fiberglass_polyethylene_other(explain)`. n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top ofoutlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,'inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of Igakage,.etc.): n/a c 7 r Page 8 of 1 I {- OFFICIAL',INSPE�CTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131 A'BBEYGATE'COTUIT,MA 02635 Owner: GOULD Date of Inspection: 7/22/02 TIGHT or HOLDING TANK:Ils(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal fiberglass_polyethylene_other(explain): n/a Dimensions: n/a . . C Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(i'fi:preserit must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 IS STRUCTURACLY S�OIJ'1VD. 9 PUMP CHAMBER:_(locate on site plan) 0 Pumps in working order(yes or no):.'NO TF Alarms in working order(yes or no):NO ' Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a 1 f -N r R Page 9 of I 1 •,i,„ ,E.l - , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131 ABBEY GATE COTUIT,MA 02635 Owner: GOULD Date of Inspection: 7/22/02 t 4 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' ; , leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a 0 leaching trenches, number, length: n/a n/a ,� t leaching fields, number: nla n/a overflow cesspool, number: n/a n/a I°�= ' innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of Hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.THERE IS 6" OF LEACHING LEFT IN PIT.BOTTOM IS AT 8 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration.'H/a Depth—top of liquid to inlet'invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no)`NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a t +, PRIVY: (locate on site plan) .f , Materials of construction: n/a ; Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a i r X 4 ` Page 10 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131 ABBEY GATE COTUIT,MA 02635 Owner: GOULD Date of Inspection: 7/22/02 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. PA A d t V d r AC I DL z g, + t, t.� • in Page 1 I of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131 ABBEY GATE.COTUIT, MA 02635 Owner: GOULD Date of Inspection: 7/22/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local'6x'c'a'va+ors; installers-(attach documentation) NO Accessed USGS database_explain: n/a You must describe how you established:the high ground water elevation: HAND AUGER- 12+FT. i A COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John.Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION . : DEP Title V Septic iInspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 ®„,." P.O.Box 2119 TeaTicket,Ma. ' ,(508)564-6813 r TRUDY COXE - t Secretary ARGEO PAUL CELLUCCI "s DAViD B:-STRUHS Governor ,Commissioner. _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 131 ABBEY GATE COTUIT 02-A ` C) Z`'I Name of Owner NANCY VAPPI - :t 11 f Address of Owner: SAME Date of Inspection: 1011/99 Name of Inspector:(Please Print)JOHN GRACI ® •r`• ' }" a, r I am a DEP approved system inspector pursuant to Secfion 15.340 of Title 5(310 CMR 15.000) Company Name: n/a 01 J^ Mailing Address: n!a OF -1999 Telephone Number: nla , y4 npN,gj� -4 CERTIFICATION STATEMENT e 9 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: X Passes ., n. The inpection is based on criteria defined In Title V Y _ Conditionally Passes r . . code 310 CMR 15.303.My findings are of how the system is Needs Further Ev lua°on By the Local Approving Authority' performing at the time of the Inspection.My Inspection does _ Fails �. ° not imply any warranty or guarantee of the longgevity of the -` septic system-and any of its components useful life. F Inspector's Signature: Date:10/4/99 The System Inspector sha ismit 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 the system owner and copies sent to the buyer,if applicable,and the approving authority. ' NOTES AND COMMENTS a A THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SEPTIC TANK NOW AND MAINTAINED EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.RECOMMEND MOVING THE TREE NEAR THE LEACH PIT TO PREVENT POSSIBLE ROOT DAMAGE. revised 9/2/98 Page 1 of 11 SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM- PART A CERTIFICATION(continued) Property Address: 131 ABBEY GATE COTUIT r a Owner: NANCY VAPPI Date of Inspection:1011199 INSPECTION SUMMARY: Check A, B, C, or D: . i m ` t f A. SYSTEM PASSES: W. ` _ 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. r t i= COMMENTS: System passes Title V inspection ' B. SYSTEM CONDITIONALLY PASSES: nLa 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. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with-i 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. Wa 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). N _ broken pipe(s)are replaced obstruction is removed ,•, , a ., ., _ distribution box is levelled or replaced' ' Wa 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 41 iT n 7 � a t J J 3 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) , Property Address: 131 ABBEY GATE COTUIT ` Owner: NANCY VAPPI Date of Inspection:10/1/99 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 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 aseptic 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 n(a_(approximation not valid). _ 3) OTHER n& y revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION(continued) x Property Address: 131 ABBEY GATE COTUIT s Owner: NANCY VAPPI Date of Inspection:10/1/99 D. SYSTEM FAILS: 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 X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool: X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day Flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n1a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: " 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 greater(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 X the system Is within 400 feet of a surface drinking water supply t X the system is within 200 feet of a tributary to a surface drinking water supply X 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 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B. CHECKLIST 1 Property Address: 131 ABBEY GATE COTUIT Owner: NANCY VAPPI Date of Inspection:10/1199 s " Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X 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: X Existing information,For example,Plan at B4O,H; X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. .t is ,.. .. e .. .. o•a 'i.:. revised 9/2198 Page 5 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 131 ABBEY GATE COTUIT Owner: NANCY VAPPI Date of Inspection:10/1/99 FLOW CONDITIONS RESIDENTIAL: Design flow:11Q g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):$ M Total DESIGN flow: = I I , Number of current residents:) Garbage grinder(yes or no): Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):•J)IQ Seasonal use(yes or no):JM Water meter readings,If available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: n&gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):JMQ 4 Industrial Waste Holding Tank present:(yes or no): MQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n(a Last date of occupancy: Wit 4 r OTHER: (Describe) n& Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: , ` OLd System pumped as part of inspection:(yes or no):NQ If yes,volume pumped W& gallons Reason for pumping: n& TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa ` APPROXIMATE AGE of all components,*date installed(if known)and source of information: THE SYSTEM IS 15 YEARS OLD- Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2198 Page 6 of 11 �, t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Property Address: 131 ABBEY GATE COTUIT Owner: NANCY VAPPI Date of Inspection:110/1199 BUILDING SEWER: (Locate on site plan) Depth below grade: 22" Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa }. SEPTIC TANK: X (locate on site plan) Depth below grade: 16" Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nla If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ nla Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: !z Distance from top of sludge to bottom of outlet tee or baffle: 2i3" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle:-C Distance from bottom of scum to bottom of outlet tee or baffle: ]4' How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PIMPING SYSTEM NOW AND THEM MAINTAINED EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_, metal_ Fiberglass Polyethylene_other(explain) nLa Dimensions: n(a Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:,n!a `4 Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: nLA Comments: M (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.) nLa A revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131 ABBEY GATE COTUIT Owner: NANCY VAPPI Date of Inspection:10/1/99 y TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wa ?` Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) , nta t Dimensions: Wa Capacity: n(a gallons Design flow: Wa gallons/day 44 Alarm present: NQ Alarm level:jita- Alarm in working order:Yes_No_ NO Date of previous pumping: n1a �. Comments: (condition of inlet tee,condition of alarm and float switches,etc.) T nLa DISTRIBUTION BOX: X (locate on site plan) , , n Depth of liquid level above outlet invert:p q LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND,SYSTFM IS FUNCTIONING PRQPFR1 Y PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) . revised 9/2/98 Page 8 of t 1 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131 ABBEY GATE COTUIT Owner: NANCY VAPPI Date of Inspection:1011/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Wa Type leaching pits,number: ONE LEACH PIT a leaching chambers,number: -nla leaching galleries,number: .ola leaching trenches,number,length: nla leaching fields,number,dimensions: nla F overflow cesspool,number: n/A Alternative system: nla Name of Technology: .nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY-SYSTEM SHOWS NO SIGNS OF FAILURE PIT PROBED DRY AT 4' CESSPOOLS: _ #' (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: Wa Depth of solids layer: nla Depth of scum layer. n/a Dimensions of cesspool: nla Materials of construction: nla Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)D& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.) g nla s, PRIVY: _ (locate on site plan) r Materials of construction:Wa Dimensions:nla Depth of solids: nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) A revised 9/2/98 Page 9 of 11 I . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION(continued) Property Address: 131 ABBEY GATE COTUIT Owner: NANCY VAPPI Date of Inspection:10/1/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks ., r locate all wells within 100'(Locate where public water supply comes into house) n/a 33 F AO a 36 revised 9/2/98 - Page 10 of 11 f ` ar SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131 ABBEY GATE COTUIT Owner: NANCY VAPPI Date of Inspection:1011/99 NRCS Report name: nta Soil Type: n/a Typical depth to groundwater: n(a µ USGS Date website visited: n(a Observation Wells checked: 1)Lt2 Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water Check Cellar ' _ Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: - Obtained from Design Plans on record _ Observed Site(Abutting 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 X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) o USGS MAPS AND CHARTS-10+FEET revised 9/2198 Page 11 of 11 ' No.f.t-07C 0Al 4-C" Fins....7.0................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -6.. .................. .. ..................OF................................................................ Appliration for Uhiposal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .......................................................... 1dress LDt N o. ....Gam.--.. ---------------------------------------- ocali.n,. 9 ail OL . . ...... .......... ............. ....../..... .... ......... .... PAAIL�;t............ &Lner address ............. .. ........., ........... -------- ------- ------ Installe� dd;e"s's* Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.......12:.................................Expansion Attic (xk) Garbage Grinder 9k Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixt s ------------------_ ......................................................................................................................... Design Flow.........33..........................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity. ..gallons Length................ Width........_....... Diameter_-___._......... Depth.............._. Disposal Trench—No..................... Width_..._............_.. 'Total Length__.................. Total leaching area.....................sq. ft. Seepage Pit No.*N1W_.v-------- Diameter....._....._.__..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by.......................................................................... Date........................................ a Test 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.....__.............__.. P4 ------------------------------------------------------------------------------------------­*.......•..............**--------------------------------*........ 0 Description of Soil................................................................................................-........................................................................ ----------------*­--------------------"-------------------*------------------"-----------------------------------------------------------------*------------------"-------------*-------------- ........................................................................................................................................................................................................ 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 TL ITI ILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Com ance has been is ed by the board(f health. gne r A— ........... .................... ................... .... .. ............... ApplicationApproved By-_... .. .......................................*------*'*'*------------- ---------- Application Disapprove! or e f lowing reasons.., --------OL&Vv ep....................................................te............... ...................................... ..... ........ ................................................................................................................................................ Date PermitNo........... .......................................... Issued_....................................................... Date No— FEE.... ................ ... ........... ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH- ...........................................OF.......................................................................................... op irFafinn forilispniial Works Tomitrurtiott frrutit Application is he_eby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .......... r ....6 - k.... In S—I ------ ,.A----.---- -- -------------- .. ......................................... . Locati? ddress r Lot No /4...........AA ..... .. ............. .../S. ...... ( J w eV ..address Install Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic jl,,kJ Garbage Grinder ( Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( P4Other fixtu es ...................................................................................................................................................... Design Flow........ .........................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank-—Liquid capacity4N.I.O."J..gallons Length____-__--___-- Width................ Diameter__-_____-___.__- Depth................ Disposal Trench No..................... Width............._._._.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit NoAP.M.P.W....... Diameter.............._..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other.Distribution box ( ) I Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.__._...............__.. ........... ..........................:......................................................................................................... .................... 0 Description of Soil......................./ .................................................................................................................................................. x 11 ---**-,*..............................................w.................................................................................................................................................. ....................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IL T 1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in 'operation until a Certificate of Compnce has been is hued by the board f health, .......... Signede-n ..... ....................... .. ................ e- --------------- c te of n S c ig e n ha s Y__ B ---- _- -- ---- --i D Application Approved By...... .. .... .. .....L/................ 0 Ing r Application Disapproved or e fo owing reasons:.. ------------------------------------------------------------------------------------------- . ............................................. ...................................................................................................................................................... Date PermitNo........... ......................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tatifiratr of Toutlifiatta THIS Is TO CERTI,F. hat the Individual Sewage Disposal System constructed ( or Repaired( by------ .. ...... ... .... ............. ................................................................................ at......zoo ..................... ...... ........................ ...... - -- ---------------------------------------------------------------------------- ................. r has been installed in accordan wi the provisions of T •I EE 5 of The State Sanitary CoXdas -.cribed in the application for Disposal Works nstruction Permit No._krl-74YI------------------- dated-... ... .......................... THE ISSUANCE OF THIS CERTIFICATE.SHALL NOT BE CONSTRUED A UARANTEE THAT THE SYSTEM WI PL F,VNCTION SATISFACTORY. DATE--. ...................................................... Inspector....... ... ......... ..............................I............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF.................................................................................... No......................... FEE..........Q......... Difivoli luo .9 on udwn pamit V r 010J.,0 Permission is h Ky gran.s .... .............. .............................................................. to Construct or R( ivid Di os � y Rep 1Z t1ks Construction Permit No Dated.......................................... U ..................................................................... ............. a .......................... ....... Street as shown on the application for Disposal. ..... .................... 7',5ki • 4�1_, of Health — ". �0*j/ DATE............... ev , 9-------------------------- FORM 1255 HOBBS & WARREN If, PUBLISHERS Lk �' ' �..��d��'�'S'°'x`6k#;..i�.•� . ,�nnn,,,„. ,.,.,�..- . . ,, �'� %Ft�_V'L•t.,,, `��/1'1C '€''. • L 4r `o " CIO j, ' lei r t 6 F, • .-77- — r^, h " r. • .ter- --- - 9. � Q �, 'a� l let - r '�r,'bj 1; l � 1 J-7.�. T�^.N K N Yl 44 ,4 7-el,'- „ f' f i„ € fhk W. tlr4ltl, Ott, f p� � "IN OFRD RICHA *MES RICHARD \u. p'HEARN y I o J�ME5 •t yi ., N,a17Y71• ce ca. p'HEARN q ,Q ,140..a4 q w 5, LEGEND EXIGTING SPOT ELEVATIONS ! • �'Xl$TaMG C0NT0UR — - 0 77 FINISHED SPOT ELEVATIONS Q.0 i;1r41§NED CONTOUR , o ; _� PROPOSED PLOT PLAN APPROVED S BOARD of HEALTH_ MASS:, I a DATA AGENT 1 CERTIFY THAT THE PROPOSED R. ✓ OWEARN, INC. RL Sit RS LOING 'SHOWN ON THiS PLAN 134A ROUTE 134 ` p,04FORMS TO THE ZONING LAW$ EAST QENNIS MASS. F` -'z Tfi =� MASS. QATh __ SCALE E N T T REGISTERED r Ai1 �U�f�E�'rUFt:. I,F!,. l i r .'"' �� E�. _,. a ^ a '�I-�'F E f ,._, OF � !' ( / r� s Y L /� f •i/ f Q :6. a e —i t •�F'XSAYani4+•'•�'"! fi yMW,.. ... . ;�.,.«7a�,. �-/' p 1 I;.� gar i elk �y } i k %b 'I► i4 Iq,, F 4 v f �JC^T �i �-• / '\�\� - (. ,���' „i is ZIA /00 CUB';C� /$.3 j IIf,�t } • /V`O.T.c, , _ ;,��,fir Cr�la S.yRG Z 12tNfA1A/ yr RICHARD cry A �r MA RICHARD G\ df * JAMES yea e4 wo•�'a D'FIEARN '+ t v �g c ti LEGEND su�,�� r' .} E'XIST)fi1D SPOT ELEVATIONS 0,,0 EX(STIG COrJTOUR - O - — - - ` + _ I-MISHED SPOT ELEVATIONS Q:Q FLIjISHED CONTOUR - 0 . PROPOSE PLOT PLAN , 'APPROVED BOARD OF NE�I� TH - A � DAT£ s AGENT' r t r ! C�R-TIFY , . THAT THE PRO 'OS E c2 Fi'. J 0 HE'A�1N, lN(,., RL lj R$ }' .11 , PUILDIN,G" SHQWN ON THIS PLAN 1348 ROUTE 134 GQI "FORMS TO THE ZONING L'AtivS N;� EAST DE IS �`, 1ASS. L N T t� rG J `P GiSTC PI"� t I; ' JJF? L' 0 R i F#. ' I� t ' ;i�f E f ASSESSORS MAP :,_ �Z / TEST HOLE L O G S NOTES: (� PARCEL : 2 _ FLOOD ZONE: A/07- SOIL EVALUATOR: �W� L�JN1,� �L`J S ► Board of � C I�� I ' 1) The installation shall comply with Title V and Town of�I I WITNESS : 1 � ,j�,iyt>W d� Health Regulations. REFERENCE: DATE : �FLG 27, ZUO°I 2) The installer shall verify the location of utilities, sewer inverts and septic �� � �� ��� PERCOLATION RATE: ,G 2.►Mt I components prior to installation and settingbase elevations. j �' 7 / Z5 2001 yE/ 1(; r �y �/ �,� 11 �/' gravity P piping 1 .2 Z 3) All avit septic i in to be 4 inch Sch 40 PVC at 1/8"per foot. The first TH- i TH-2 two feet out of the d-box to the leaching shall be level. Ssms Mrr R '^ P property line determination nor any other Q 4) This plan is not to be utilized for ro se other than 5) All septic components proposed meetitle V specifications. 6) Parking shall not be constructed over H10 septic components. f�ln I �.1 I 7) The property is bounded by property corners and property lines. LOCATION MAP ' + to a2/1 8) The property owner shall review design considerations to approve of total 146 _ design flow and number of bedrooms to be considered for design. Receipt Svt�(0 of payment for the plan and installation based on the plan shall be deemed �r 25 (o14 approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material C, G per Title V abandonment procedures. Those within the proposed SAS shall GL�4 e ��' � be removed along with contaminated soil and replaced with clean sand per 4��j a� t 1� I� Title V specs. all)+ ,0 i ' c> tt p 1p-"-t& ----Wb-top,W4L- 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service SEPT I SYSTEM DES I G N line. The line is to be sleeved as aforementioned and maintained in place. �' --- --- I 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW ESTIMATE owner to ensure such. 12)The installer is to take caution in excavation around the gas line if such exists. 'In BEDROOMS AT 11 D GAL/DAY/BEDROOM - '�� GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer SEPTIC TANK lines exiting the dwelling prior to the installation- GAL/DAY x 2 DAYS - Lc .l GAL USE 000 GALLON SEPTIC TANK ►}117 SOIL 6SORPT I ON SYSTEM �. r . r�ppuul0 1T! W� (� 31 DE AREA: x -� A Z Y . ' BOTTOM AREA: j. - / -- - " cto 0F'``� Cubes- � �--- •� 1 ,� i '� u�� '�'�-�-"�'�'� ,' --� ��. DAVI _o o s ► , _.... EPT I ., SYSTEM SECT I ON K 1 = 4C, Id�tY. V `_ I I !1t O GAL - SEPTI TANK JIM v 7 f r S I T E AND SEWAGE PLAN � 3 v�2, AD �1� L- N— _._ LOCATION 13 1 ei �` )t Cl �' b�lv�_ NCI rPl�� r '.J n �dvZ�. `C>,T- j '? PREPARED F 0 R • - t��( , (((, )ID 11A — _ -___ ✓/ SCALE: I /% fO ' DAV I D B . MASON DATE: 5 ZI D DBC ENV I RONMEN�AL DESIGNS EAST SANDWICH . MA DATE HEALTH AGENT z ( 508 ) 833- 2177