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HomeMy WebLinkAbout0057 ANCHOR LANE - Health V57 Anchor Lane COtuit P A = 024 092 i II a ,i No. cU, 1 ?2 V/ Fee Id�— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpphration for Disposal 6pstrm Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address o�Ljot No. Nc�p(0j, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel In,1sTtaallleer's Name,_Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: "f Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 45/Jm"a No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3G/y gpd Plan Date I��if 5 Number of sheets Revision Date Title Size of Septic Tank xh� Type of S.A.S. 02 � Glz�� —/(�(ki $ W 4_y� Description of Soil Nature of Repairs or Alterations(Answer when applicable) ' `e' l rJew asif C,_ 2. 4 s00 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date r-16 tJ Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �C( �/f Date Issued ! �J GJ _.._ No. ,�1 W , s:_..� 3��y Fee r THE COMMONWEALTH OF MASSACHUSETTS Enteredincomputer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Disposal Epstein Construction Permit low Application for a Permit to Construct( ) Repair(0`0'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or,Lot No. Owner's Name,Address,and Tel.No. Assessor's Map= a t,l cl 2 �i1 N14 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: w Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building � /� �� No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow(min.required) 1,:50 '. gpd Design flow provided :?r,q, gpd Plan Date Number of sheets Revision Date Title • Size,of Septic Tank Type of S.A.S. Description of Soil . Nature of Repairs or Alterations(Answer when applicable) P �i�: �,./ o� —� �b - r ul✓/ ' Ir Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by ffi tti► Date y> 4.Application Disapproved by Date "for the following reasons Permit No. j j// Date Issued .I ----------------------------------------------------------------- --------------------------------------------------------------------- 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 at . �� �j„�i/ „i,o 6�'>� s i as been constructed in accordance witt the provisions of Title 5 and the for Disposal System Construction Permit No. r ated </ C '�`Insller��,�, Designer #bedrooms Approved design flow 'y) gpd The issuance of this permit shall not a construed as a guarantee that the system will !['Cbj,/ndesigned. Date ( /q Inspec No. 1 �j Fee lap THE COMMONWEALTH COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Nsposal �pstrm C nstrUctlon Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at 4 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her I:14,,to comply with Title 5 and the following local provisions or special conditions. i Provided:Construction must be completed within three years of the date of this permit. Date Approved by A i Y Town of Barnstable Inspectional Services 1 Public Health Division BAMrAB Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: '7 Sewage Permit# ;A0 'i Assessor's Map\Parcel Zq 9 Z Designer: � 1✓ � Installer:: �- Address: i = — - Address: On 8`_fS --G/"`�i was issued a permit to install a (date) (installer) I septic stem at L�{D� lJ� �y� based on a design drawn by p y (address) dated 0�� (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in • ce with the to rms of the INA approval letters (if applicable) -\k\OF Mq sy �S I DAVID S. U staller's Signature) o MASON m No.1066 0 �� /STS"" SA (Design Signature) (Affix Des p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. \\toa\depts\HEALTMSEWER connec6SEPTICOesigner Certification Form Rev&14-13.DOC Q TOWN OF BARNSTABLE LOCATION S7 A,"G,, },.o SEWAGE#�20(cf_ VILLAGE ASSESSOR'S MAP&PARCEL Y Z_ INSTALLER'S NAME&PHONE NO. A� �-�E,,,,i �n.0 SEPTIC TANK CAPACITY L xl�j tl LEACHING FACILITY:(type) (size) �i 2.A X%5. — NO.OF BEDROOMS OWNER //—/ .ni c - PERMIT DATE: COMPLIANCE DATE:-9_l y—/ 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 �i A o�fi y s ID-4.3 57 ANC1\D',� ,• Bo-- 213 D - 1 — 41 der TOWN OF BARNSTABLE ' 4L.00ATION SEWAGE # VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. J `\ SEPTIC TANK CAPACITY /OU LEACHING FACILITY: type) k�_ (size)(OA NO. OF BEDROOMS L BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 161- Feet I Furnished by '_—< \► �h�i� t AA gcA M uq i Ac �b d eCIG AD ©i1 PA �iL a 0 � " L'O CAT ION SEWAGE PERMIT NO. (7 VILLAGE (f 0 7U � - � � aa � INSTA LLE 'S NAME i ADDRESS I U I L D E It R OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED T- L 0 ® r o T4tj dvse r � � �OR.IY6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Anchor Lane, Cotuit M-24 P-92 Property Address r�5 Sara Stockhaus Owner Owner's Name :. information is required for every 57 Anchor Lane, Cotuit IX MA 02635 September 3, 2015 ,a:a page. City/Town State Zip Code Date of Inspection :M. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Troy Williams use the return Name of Inspector key. Troy Williams Septic Inspections �y Company Name 19 Hummel Drive Company Address South Dennis MA 02660 Cityrrown State Zip Code (508) 385- 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority September 3, 2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �'q Y,)t/ \I r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is every 57 Anchor Lane required for eve , Cotuit MA 02635 September 3, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is 57 Anchor Lane, Cotuit MA 02635 September 3, 2015 required for every _ P page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health)- ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑, N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 L Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is required for every 57 Anchor Lane, Cotuit MA 02635 September 3 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r 5 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'" 57 Anchor Lane, Cotuit M -24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is required for every 57 Anchor Lane, Cotuit MA 02635 September 3 2015 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner owner's Name information is 57 Anchor Lane, Cotuit MA 02635 September 3 2015 required for every P , page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is required for every 57 Anchor Lane, Cotuit MA 02635 September 3, 2015 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 14=68,000 gals. g ( y g (gp ))' 13=72,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is required for every 57 Anchor Lane, Cotuit MA 02635 September 3, 2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): NIA General Information Pumping Records: Source of information: No pumping info was available. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is 57 Anchor Lane Cotuit MA 02635 required for every � September 3, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank, d-box and leaching were installed on 12/12/79 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"+feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'X9'X6' 1000 gallon Sludge depth: 4" t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is 57 Anchor Lane Cotuit MA 02635 September 3 2015 required for every � P , page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2' 8„ Scum thickness 2., � Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? probe/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.): Inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Pumping of tank at this time is recomended. Grease Trap(locate on site plan): Depth below grade: N/Afeet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet 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 Date t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is 57 Anchor Lane, Cotuit MA 02635 September 3, 2015 required for every P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/Agallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Anchor Lane, Cotuit M -24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is required for every 57 Anchor Lane Cotuit MA 02635 September 3, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level 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 was found level and in working order. 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.): N/A * If pumps or alarms are not in working orders stem is a conditional ass. P P 9 � Y P Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Anchor Lane, Cotuit M -24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is 57 Anchor Lane, Cotuit MA 02635 September 3, 2015 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 -6'X6' pit with 2 of stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was found with water level approx. 18" below inlet invert. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Sprinkler line above cover. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/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 ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Anchor Lane, Cotuit M -24 P-92 Property Address Sara Stockhaus Owner Owner's Name -nformaequined for every tion is require 57 Anchor Lane Cotuit MA 02635 September 3, 2015 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): 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 .t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Anchor Lane, Cotuit M -24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is 57 Anchor Lane, Cotuit MA 02635 September 3 2015 required for every P , page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately G.►�,hw�;�..� r to r _ O t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is 57 Anchor Lane required for every , Cotuit MA 02635 September 3, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 13.0'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: SDW 253 Zone B 50.2' 4.4' adjustment You must describe how you established the high ground water elevation: Hand augered 4.5' below bottom of leaching with no water found at a depth of 13.0'. Groundwater adjustment at the time of inspection was 4.4'. Bottom of leaching at 8.5'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•'' 57 Anchor Lane, Cotuit M-24 P-92 Property Address Sara Stockhaus Owner Owner's Name information is 57 Anchor Lane Cotuit MA 02635 September 3 2015 required for every � p page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_57 Anchor In. Owner's Name:_William Holland Owner's Address:_57 Anchor in.Cotuit,Mass Date of Inspection:_11/19/08 514 ,5 2— Name of Inspector:(please print)_Eric Stevens Company Name:_E.Stevens Construction,Inc. Mailing Address: P.O.Box 71 Marstons Mills,Ma.02648 Telephone Number:(508)776-9054 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal sy ems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMMR 15.000). The system: Passes Conditionally Passes c� _Q Needs Further Evaluation by the Local Approving Authority c JZ Fails 7Z Inspector &Signature: � Date:__4 ell' ^? he system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow-of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments System was in good working order and passed Title V inspection. ****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. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) �210� Property Address: 57 Anchor hL Owner:_William Holland Date of Inspection:_11/19/08 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 55.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is sound and working correctly.Pit had 14"water and no staining over 3. B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_57 Anchor In. Owner:_William Holland Date of Inspection:_11/19/08 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "Thus system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_57 anchor In. Owner:_William Holland Date of Inspection:_11/19/08 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each 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''/s 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 x_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _x_ Any portion of 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 1 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,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] . NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_57 Anchor In. Owner:_William Holland Date of Inspection:_11/19/08 Check if the following have been done.You must indicate"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 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 of water 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) Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? x Were all system components,excluding the SAS,located on site? _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? i 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: Yes no x _ Existing information.For example,a plan at the Board of Health. _x_ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_57 Anchor In. Owner:_William Holland Date of Inspection:_11/19/08 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 4 Does residence have a garbage_grinder(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):_ Seasonal use:(yes or no):—no— Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy:present COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/persons/sgff,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— f Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: homeowner Was system pumped as part of the inspection(yes or no):—no— If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: 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): Approximate age of all components,date installed(if known)and source of information: Approx. 15 yrs. old Were sewage odors detected when arriving at the site(yes or no):—no— OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_57 Anchor In.. Owner:_William Holland Date of Inspection:_11/19/08 BUILDING SEWER(locate on site plan) Depth below grade: 2' Materials of construction:_cast iron _40 PVC x other(explain): Distance from private water supply well or suction line:_town water Comments(on condition of joints,venting,evidence of leakage,etc.): No leaks,mortar is solid. SEPTIC TANK:_X (locate on site plan) Depth below grade:_18" Material of construction: x concrete metal fiberglass_polyethylene_other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):'_(attach a copy of certificate) Dimensions: 1000 gal. Sludge depth:_2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:_1" Distance from top of scum to top of outlet tee or baffle:_6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined:_measured- sludgejugde Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tank is sound and both T's are present GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:_concrete metal fiberglass_polyethylene_other(explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_57 Anchor In. Owner:_William Holland Date of Inspection:_11/19/08 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: iallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_x (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-box is sound and working correctly.No sign of solid carryover PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_57 Anchor In.. Owner:_William Holland Date of Inspection:_11/19/08 SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not located explain why: Type _x_leaching pits,number:_I (1000gal.)_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): Pit is sound. 14"water at time of inspection.No staining over 3'. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_57 Anchor In. Owner:_William Holland Date of Inspection:_11/19/08 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. l i 17 ,'Ll a z: L1 H'Iz aZ Z A3, g ' y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Anchor Ln. Owner:_William Holland Date of Inspection:_11/19/08 SITE EXAM Slope x Surface water x Check cellar x Shallow wells x Estimated depth to ground water >13' feet Please indicate(check)all methods used to determine the high ground water elevation: _x_Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) x Accessed USGS database-explain:_internet You must describe how you established the high ground water elevation:_Pere test from install plans and usgs website 14- 11 ^ r� COMMONWEALTH OF MASSACHUSET 1 S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 W FEE i D � , d p eW J U L 2 9 200, TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A' CERTIFICATION Property Address: 57 ANCHOR LANE COTUIT,MA 02635 lJ�� Q�C Owner's Name: HALLOWELL . Owner's Address: C/O PAM HORN 23 TRIANGLE CIRCLE SANDWIC 1,MA 02563 Date of Inspection: 7/1/03 Name of Inspector: (please print) JOHN GRACI, INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 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 infor.nation reported below is true,accurate and complete as of the time of the inspection.The inspection was per formed based on my training and experience in the proper function and maintenance of on site sewage disposal systei.is. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Cojaopy es _ Neluation by the Local Approving Authority Fa Inspector's Signature: Date: '.71/03 The system inspector shall suhis inspection report to the Approvint,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 "ice of the DEP. The original should be sent to the system owner and'copies sent to the buyer, if applicable, and the approv'.ng authority. Notes and Comments V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONGTFIE, SYSTEM PASSED TITLE , SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under are conditions of use at that time.This inspection does not address how the system will perform in the future under the sarne or different conditions of use. -i -nnn � f Page of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 ANCHOR LANE COTUIT,MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 w a Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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. c Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. 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 break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page-of11 } OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 ANCHOR LANE COTUIT,MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in,order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. F _ 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 n/a - "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and r volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: y n/a ;, Page T of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 ANCHOR LANE COTUIT,MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each 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 ''/z 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 n/a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of 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. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000gpd to 15,000 gpd. ' 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) yes no _ X the system is within 400 feet of a surface drinking water supply 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 If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. A Page 5 of 11 OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 57 ANCHOR LANE COTUIT,MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 Check if the following have been done. You must indicate"yes" or"rio"as to each of the following:. Yes No X _ Pumping information was provided 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 of water 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 X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site 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 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: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Pager d'of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 57 ANCHOR LANE COTUIT,MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 FLOW CONDITIONS RESIDENTIAL 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 . Number of current residents: 0 Does residence have a garbage grinder(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): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):-,49Ga a - S QC) Sump pump(yes or no): NO Last date of occupancy: 12/31/02 0 - s(C)ob COMMERCIAL/INDUSTRIAL 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: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO - If yes,volume pumped: n/agallons--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 components;date installed(if known)and source of information: 20 YEARS BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 ANCHOR LANE COTUIT,MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC, Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage, etc): TOWN WATER s SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO.(attach a copy of certificate) Dimensions: 1000 GALLONS" - Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" " Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" . Distance from bottom of scum to bottom of outlet tee or baffle: 16" 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 EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain):n/a Dimensions: n/a. , Scum thickness: n/a Distance from top of scum to top of outlet 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 leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 ANCHOR LANE COTUIT,MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 TIGHT or HOLDING TANK: (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 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: _(if present 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 STRUCTURALLY SOUND. " PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): n/a R Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 ANCHOR LANE COTUIT,MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 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 n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a 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. PIT WAS EMPTY AT TIME OF INSPECTION. STAIN.LINES INDICATE PIT HAS NEVER HAD MORE THAN T OF LIQUID IN IT.BOTTOM IS AT 8'6". CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a s 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 PRIVY: (locate on site plan) ` 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 0 Page 10 of 11 I _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION`(continued) Property Address: 57 ANCHOR LANE COTUIT,MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 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. 4A �a AB kV AP L a to Page'l•l of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)' Property Address: 57 ANCHOR LANE COTUIT, MA 02635 Owner: HALLOWELL Date of Inspection: 7/1/03 „ 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 systeadesign 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 excavators, 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. p7f 0. 377 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF H ALTH OF...... a.. �..�........................................................... Appliration for Uhiposal Workii Tongtrnrtiun ramit 1H Application'is hereby made for a Permit to Construct (N) or Repair ( ) an Individual Sewage Disposal Systat -- ------•----•--•------ ----- .----- �o ,�. tYddress� ` or No. Address Ile Installer Address Type of Building Size Lot. .......Sq. feet V Dwelling—No. of Bedrooms.. __.._.___ ..___Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ... .. ..........V No. of persons......6.................. Showers ( ) — Cafeteria ( ) Otherfixtu es ...--••••--••----••-----•------•-------------------------•-•--•--•••-••---•-•••-•••••---------•------•--------•••••-•--•.....----•------•-•-•-.------ Design Flow........u .....................gallons per person per day. Total daily flow----------3.3.0...................gallons. WSeptic Tank—Liquid capacity............gallons Length o.4_K". Width. `"_ Diameter---------------- Depth................ x Disposal Trench—Ns-------------•------- Width.................... Total Length................ Total leaching area..............'..sq. ft. Seepage Pit No......../----------- Diameter-----/__.__..... Depth below inlet...7.1...... Total leaching area„�,4J__._..sq. ft. Z Other Distribution box (® ) Dosing t"k ( ) l~' Percolation Test Results Performed by---_g__.._t f.�.:.. ..... ..... ................. Date-J... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_VQ_ - 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-Q.. W ••••------••--------------••------..........-••••...._......------•-------••.........••••--......--•......................................................... 0 Description of Soil......... ...... V . - - - - 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 TIT IL- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by t boa .o of health. Signed•--. ... ...... -------------•--•-----•- �...// Date Application Approved By____________ ....... �----- •. ......-c am-- ..... -------- --.-�- Date Application Disapproved for the following reasons:.................................... - ------------------------------------------- ----.............. ..............................•---------...---•--•------•--•--------------------•---•-•-----•-•-•-••....._ /7 � �� r Date Permit No. .._. Issued _ -----------•-•••••......•----------- Date Fizim........ .. ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................................................. ..................OF...... Application for 0hipasal Marks Tamitrurtion Vrrmii Application.is hereby made for a Permit to Construct (N or Repair an Individual Sewage-bisposal System at - ----- 1 e11� 7 -------------- •.......................................................i......... -------------;;--------------------------------------------------------------------------...... Address or•Lot No. Address ------------------- ---------- ----------------------­- .......... --------------------------------------------------- ........ 0-7 ......................... ................ ------------------------------------------- ................7................................................................................ Installer Type of Building Size Lot"ZNW_7-------Sq. feet —No. of Bedrooms............................................Expansion 6 Garbage Grinder Dwelling Attic Other—Type of Building No. of persons......!�.................. Showers Cafeteria 04 Other fixtures ........................... ..................................................................................................................... Design Flow.......... . ...........................gallons per person per day. Total daily flow------­ -------------W --- .....gallons. ---- Septic Tank—Liquid capacity............gallons Length._2."&_ '. Width. Diameter---------------- Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No -. ...... Total leaching area..-ftZL�__sq. ft. -------- --------- Diameter...../n__1....... Depth below inlet... 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.ZZ�_A,6-&,C 44 Test Pit No. 2................minutes per inch Depth of Test Pit__.__............_.. Depth to ground water. ..._« .... 94 *-------------------------------------------------....*----------*-----*--------------"-------------------­------**......*-------------------------------- W0 Description of Soil..................................... ........................................................ .................................................................. ...................................... .....�Akw U - --_-------- ------------------------------------------------------------------------------------------------------------------- W �4 ........................................................................................................................................................................................................ 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 I Tig, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certifica'te of Compliance has been issued by the board of health. Signed ... .......................... ................................ .......... y ..............­---------- Date Application ApprovedB:............. . .. .... ---------6 NO Application Disapproved for the following reasons:..................................... .................................................................... ................................................................ ....................................................................................................................................... Date Permit No................... Issued-,- ---------------- ---711-1, k",................................................. Date THE COMMONWEALTH OF"MASSACHUSETTS BOARD OF HEALTH ................OF........ ........................................................................... Tertifiratr of Tom- pliaurr t '4�r. n Repaired THIS IS TO��-ERTIEY Tha e Individual S6 age Disposal System constructed by........ .............................................................................................................................. ... ....... ......... ------ at_.. ?- ....17. , ................................................. inst�er Installer .. ....... ... . ................................................. has been instille n accordance with the pro of 5 of The State Sanitary Code as described in the application for Disposal Works Construction ;SriO4-s t NOL ?........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... In9P ector.................................................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 OF HEALTH 7? 7 7 11.,el .................OF..... ) 4&- C- .......................................................................... No.......... --••----... FEE., 1__,............ Disposal Workii Tomitrurtwu rrrmit Permission is hereby granted......,] ..._..__..._... *` - Z��....*........................................................ to Construct or Repair ( ),an Individual Sewage Disposal System at No.---- 2..........Z7......2. ....... ..;7 t, ....z - --------- ........................................................................ W�U7770G'4tt, , Street 11 as shown on the application for Disposal Works Construction P ............. D ......... ........... .. ..... ... ------------- and He It DATE........ ....................................................................... FORM 1255 HOB19S & WARREN. INC., PUBLISHERS* iASSESSDRS MAP: .,, � �- "" - �_. TEST HOLE L O � 1) The installation shall comply with the State Environmental Code Title V and Town of PARCEL Board of Health Regulations. FLOOD ZONE: /� c�J � �Ir� � SOIL EVALU TOR. l �) 2) The septic system as proposed on this plan shall not be installed until a licensed town installer '�- REFERENCE; receives approval and an installation permit from the applicable town. ZIPDATE: 4 3) Prior to installation,the installer shall verify the location of utilities,sewer inverts, sewer lines _W R¢ PERCOL.AT l 6N RATE : �� � . `l� and existing septic components prior to installation. _ ..__-� � L.,.„ ► / °°� 4) All gravity sewer piping is to be 4 inch schedule 40 PVC at 1/'8" per foot. The first 2 feet out of > l TH- I TH-2 the distribution box shall be level. All piping connections to be glued. 0 # f I 5) This septic design plan is not to be utilized for property line determination or for any other -- � ` �/� +,!�, ! purpose other th�.n the proposed septic system installation, u �v ?�� 6) All Title V comporents are to meet Title V specifications. � L ( , , , 7) Parking shall be prohibited over Title V components uniess components are H2O loaded. AP ` ' s� e r cesspools shall fill with material Ti V LOCATION � � � 8) The exiting leaching o ssp be pumped and filled t ater a)per tie abandonment procedures. Leaching and cesspool(s)and contaminated soils within the A proposed SAS shall be removed and replaced with clean sand per Title V specifications. fX 9) Septic components are to be 10'from a water service line.Sewer lines crossing a water line shall 0 % be sleeved with an appropriately sized schedule 40 PVC with ends grouted. The water service line or the septic line can be sleeved with the sleeve being a distance of 10'on bct s,_,A?s zi1 crossing the line, t 10) If a garbage grinder exists in the structure, it is to be removed if the septic system is not 9 "1 0 designed to accommodate a garbage grinder. SEPT 11)The installer is responsible for care of excavation around all utilities on the property and protecting the structural integrity of all structures during the installation process of the septic system. _ FLOW EST I MATE k IT _l 12) This plan only represents that a septic system can be installed on the property meeting Title V / , -� . � requirements. ' i .� BEDROOMS AT 0 CAL/DAY/BEDROOM w AL/D AY13) The property owner shall review design criteria to approve the total number of bedrooms and design flow. Installation of the septic system as proposed and receipt of payment for the design SEPTIC TANK shall be deemed approval of the design criteria by the property owner or agent of. - -- -- - "� 14) The validity of this plan shall expire with the expiration of the town installation permit issued for GAL/IAA a x 2 DAYS ' GAL / , f / this plan or the validity of this plan shall expire on the expiration of the Certificate of Compliance USE GALLON SEPTIC TANK .t :q! .. issued for the installation of the proposed system on this plan. eb) J 90 ;;C� rA i$Plr ? YSTIM. '' ...4 \1 f mac.- 0, -- , ! �HOF/tj fi. ._A ;SIDE' AREAS �, _ I �, s .-° BOTTOM AREA ' '� ' �� � ~�2�� ��� sy� _� __.. Y mow.--r.:.��. � •Mk DAVID B G MA§ON ' No.106t%d cam , SEPTIC SYSTEM SECTION 1(JlTAR /off -.-'- __ 1A_ ._. � jj _ IV 1 �' '� r A. � ' All SEPTIC TANK ,. 7.0 � _w �k A SITE AND SEWAGE PLAN (AM VIA PREPARED FOR : \ � m a SCALE : DAV i D B . MASON,R' DATE 4� � g DBC ENVIRONMENTAL DESIGNS x r DATE HEALTH AGENT f _ FF. tfl�•',747 ! / F;N�SH :iP.opt=` 74 - Fl,Pv(SN GQAT� Ar,S�r v1TAT'c'r _ TOP GtE► � - c ..� �4•.c '�• 1r .,i .. f _._�_..._... _. _ �� c,,,n.".ret .vr.rz•.^3c� t?7.�1C�tti/EGG We t.tNG Etc A C� F',j. /aod cs•�z. x o�rG<.i* - I� £ �� ! �. �J f !•�„ _ ____ ._ - __ _{ ,' �'frNt�E.'GEL� c:"C/�•G / M� � � a 1: fibf{ - � 9N�r. „^rA.v�' 4 _ W \ � is / I/ .t.C• � C C. { _ ,'_'ti'�t`C. T�,4:t'K• �...«_ _ " -TG C3E C.f'Vf't• �� / d ; y r ! E �'!,t�;,,s� "1!.•'•``r+t.`�`�%/'!�`.'�j!//i(►`*,�>-'.'t�'•!,/,�t,�j, 7i;,+ '�T7�/"� D t" i►rf ,^war Tn ,era• .:=f- .!!€ram t�"+�o.M�► ,.�_ � f # GAS.•• !�'E'4 L�q y : �u._t?.._ ,.C.c1�''- rl 4- � _.._.� /�c�•dam ?/.3 TOTAL fi./vIP�L�/ F20W., 2.e' a .7 '4w jlt'. x /8Z k 2 4S.S' 3.3e /40',9 At-A-P rf i N F - 74 p -.1 yyy� COO";+A �Ozl 7�I.Utl. �.yJ� ,•/L 3 N f 1 6 3 f +'i V L r(;lZ.Q !✓ . 4�•s1/U/ ` " + u ", . !��°`I�[ c''s l; >-, .`✓ t A< FJ_ o.;i M.S•L "I>A Tcr,�! . /f+ _",. . _�` �" .T^UN� t 1�z Zz)7 :S -&A/ Ow^teje 'CAMAR A4CPhS R45J0t-7"r TUUST R. �, ?.�N� S. V'PM t 4 rN � /�'1 A 1 r ,1' " r <�+�;. r rt '�A ' ► � A mod, ' 'r,,� �� Mr= Y �r ail► /7 - ,� Abvwr Je _ i.....as1�.+.+�:,e--"*�...�..».w+.w.•rri.4�*r.....+.—.+.w.y-............�.-«...,�.....*,..-+-,.,�'-...... .......+....w...,......«�i.rrw•...-...-....*....-:,�.a- ._..w,.. .,.-_.-..«...._-..,®r....,+...,..,..,,».�..rw.«-+sii+�, ..h.,�»a..««....w....T.m...r..�...,• -+u.'.+•M,•...wo-,,w.«...,.,.w+�aC..:.a+n+,...6e1►.w'v�_.w.�ww•.a.e<u�+*rRai*+w ., .n .."<, .... .,_..,.,a