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Home My WebLink About0071 ANCHOR LANE - Health 71 Anchor Road Cotuit - --- _ A= 024-107 -- - --- - —— No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Misposal 6pBtrm Construction i3Prmit Application for a Permit to Construct( ) Repair(V� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �nG�i10� t.W-_Q. Owner's Name,Addressand jel.No. Assessor's Map/Parcel O 7 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Oj Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3.3® gpd Design flow provided r 0 gpd Plan Date��(-L (CD Number of sheets Revision Date Title Size of Septic Tank 4aA�k woo Type of SIP ),r,, -Na .f�S i z 0 � Ccic Description of Soil rnseu COc Nature of Repairs or Alterations(Answer when applicable) c e o X G S n(h 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 Bo of Health. d Date Application Approved by 1 Date ' Application Disapproved by Date for the following reasons `1., Permit No. Date Issued i a No. V V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Disposal Epstein ConstrUttion permit i Application for a Permit to Construct( ) Repair(t/f Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ( �nL C of (�� Owner's Name,Address,and el.No. Assessor's Map/Parcel O Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. � 0 S co* , kv \a Q_j Sj-Cv�. �cc.c,� e� � ,spy t7b� �� a Type of Building: ? rr\\ Dwelling No.of Bedrooms \ Lot Size sq.-ft. Garbage Grinder(,qo Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow(min.required) J 2 0 gpd Design flow provided /_ C7 gpd Plan Date_SS- f(ct �(c Number of sheets Revision Date Title Size of Septic Tank lobo `Type of S. .AID � _ j V Z o PrT ccor Description of Soil LpC-rr Nature of Repairs or Alterations(Answer when applicable) p ,p`4c 0 y t�_ �t� 3� t 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 Bo�Health. Date Application Approved by '' Date Application Disapproved by Date for the following reasons Permit No. Date Issued ------------------------------------------=-------------- -------- --- - ------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS - Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( L<<pgraded( ) Abandoned( )by �.xck\ at ` A�t� � � [ r�� C4,;- -has been const cted in accord nce with the provisions of Title 5 and the for Disposal System Construction Permit N . dated Installer skz:> �-� ( Designers__ #bedrooms Approved design flow C1 gpd The issuance of t is permit shall not be construed as a guarantee that the system will func' n asd signed. Date S1� � 10 Inspector t[ Vv- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS Disposal 6pstr Construction 3Prmit Permission is hereby granted to Construct( ) Repair(�/) Upgrade( ) Abandon( ) System located at `� A r,6—or L.c,.R__. C y';N1r� 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 be c le within three years of the date of this permit. Date t� Approved by r Town .of Barnstable OF THE 1p� , yP� ti� Regulatory Services - Thomas F,.Geiler, Director IARNSTABLE, T1 '1 ASS. Public Health Division A p e rfD MA'S Thomas McKean,Director 200.Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: a� a ;v Sewage Permit# Q C)\ Assessor's Map\Parcel l C1107 Designer: STEP R641,�' A. ViAA51 PIE SC Installer: cTT-, ►.t. F�)t._ EK.c-E S0" t Azq. !uL. Address: 92.3 Z Cody Address: 11 t Dt-`D YA2_A6mTiM L:b. ` A-P k av7-r+fb P-�l HA H YA-uki t S, M A. �2l0o j On�Lt l D _ 1�• RE—/0,► k— was issued a permit to install a (date) (installer) septic system at based on a design drawn by (address) 5 K P H =t► A. dated 11 (design'er) ___ZI certify that the septic system referenced above was installed substantial) according t the design, which may include minor approved changes such as lateral relocation f the distribution box and/or septic tank: I certify.that the septic system referenced above was installed'with major changes (i.e. greater than'l 0' 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. . � <yk p�il9a Ci . (Installer's Signature) At '� (Designer's Signature) (Affix Designer's Stamp 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 BARNSTAB PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Revised.doc < n, TRANS. NO.: CITY/TOWN: APPLICANT: ADDRESS: —7/ Cx DESIGN FLOW: gpd REVIEWED BY: si'Z��-t—�—+—' t- '� DATE: S / N/A OK NO .0 t;"�z�S v �r3r8 R r .. ME, ' Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(0] daily flow septic tank capacity(required and provided) soil absorption system(required and provided) ✓ whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and pro osed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)] Location and date of percolation tests (performed at proper / elevation?) [310 CMR 15.220(4)(1)] ✓ Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR V/ . 15.220(4)(n)] Address [/.o 7 Sheet 1 of 7 N/A ' OK NO Location of every water supply, public and private, [310 CMR , 15.220(4)(k)] within 400 feet of the proposed,system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case ✓ within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[l]) Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required,if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benclunark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not> 36" deep (unless Local Upgrade Approval or LUA requested) [310 CMR 15.405(1(b)] `� Address Zq /to Sheet 2 of 7 f N/A OK NO ..4" :`3`s.„i�C'ffi✓.,.�.,..�,iwxL`' S'� .L`:''�.-2 VE�Y£�i'/d°a Size OK? [310xCMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter[310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(l)] Separation between inlet and outlet tees (no less than liquid / depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for / upgrades under LUA [310 CMR 15.405(1)(k)] '/ Minimum cover 9" (Tanks buried more than 9"must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater)- middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<1000gpd, two for systems >1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] 'z'70 <a Multi Compartment Tanks � � �� Yr °9PIT f Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15.223(1)(b)] First compartment 200% daily flow; Second compartment 100% daily flow [310 CMR 15.224(2) and(3)] "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address 21110 -7 Sheet 3 of 7 N/A OK NO BT7ILDING°SEWER AND OT=H R PIPING � �� .. �. Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18"below water line(when water and sewer cross, see 310 CMR 15.211(1)[11) Cleanouts required/provided? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches / and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphon problem/(leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base [310 CMR 15.221(2) and 310 CMR ✓ 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(f)] Ij Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd);waterproof manhole if>2000gpd / [310 CMR 15.232(3)(d)] _'•9""'�` `e ` �0.271 F'.'^'Wv�ro'� .�` += a` ��'��'v a 4 HAMBER� � ��F, ; Capacity(emergency storage above working—design flow)? [310 ✓ CMR 231(2)] Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in miniuin access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and(8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed? Provided? [310 CMR 15.221(8)] Address Z`��° Sheet 4 of 7 N/A OK NO SOILABS;QI2PT'T01��SYSEi�IS"�SS) FERAL � � . Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR / 15.240(1)] V Required separation to groundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation ' within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] GAT LERIES;PIT S;CIAMBERSM310y;CM]2 5253�� ' � ~ i L� Chambers and Gal. in trench configuration supplied with inlet / every 20 ft. [310 CMR 15.253(6)] V Each structure with one inspection manhole(if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate I' minimum- 4'maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)1 zT12ENCIES310 CYIR1f5251 � �SUN. av � Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] 100 feet- maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] �t BEDSAS aximut �ze�ofsb11 ed olfiel000 d4 � � � � minimum 2 distribution lines [310 CMR 15.252(2)(a)] ' Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10'minimum. [310 CMR 15.252(2)(0] Bottom area used in calculations only [310 CMR 15.252(2)(1)] Address 2 '7 Sheet 5 of 7 N/A OK NO F£LAl r , Pressure Dosed System ? Provided pump and piping / calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and UA Remedial Use Approvals] If used in gravelless system -make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000gpd) good to note on plan [310 CMR 15.254(2)(d)] Construction in fill - Did the plan specify that the fill shall meet V/ the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional t/ Engineer [310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and V Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. - recommended) [310 CMR 15.255 (2)(e)] Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface UM. AlterriatieSe fic S stem AAA royal Le erg x: q RE Was DEP Approval Letter provided and/or have you / reviewed the letter for conditions? V Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Are the variances listed on the plan? [310 CMR 15.220 (4)( )] RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 1.5.414] Address 2'�/� Sheet 6 of 7 N/A OK NO �r 5...��..c� Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and / 310 CMR 15.216 - also refer to Policy regarding upgrades of such �/ existing systems] Is the system proposed on the same lot as served by private well ? 1310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR / 15.216(1)] ✓ x10, Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] Address 2°{�/ �' Sheet 7 of 7 d ' I lrTl TR 7 „1 S1 .7 of rl r - 1� lol RN o a r Cn R D n r 71 YJ .t" 1 ,J CA All C h oF� Town of Barnstable P# Departinent of Regulatory Services Public Health Division 011 Date 3/��O 200 Main Street,Hyannis MA 02601 Date Scheduled b Time•_ Fee Pd. Soil Suitability Assessment for Sewage Di posal T Performed By: ST�P/i G� / 5 PE: Witnessed By: v` LOCATION& GENERAL INFORMATION Location Address r /� Owner's Names Cv Address Assessor's Map/Parcel: I�� ' � Engineer's Name �.�v..�`,S�-��S �GG NEW CONSTRUCTION 1J REPAIR Telephone# S�2j 3(�a �(� I Land Use )0-6'5 Slopes(g'a) LZ— Surface Stones .t U Distances from: Open Water Body f'Ft - ft Possible Wet Area—4z±_ft Drinking Water Well 1 * ft Drainage Way f% !a- ft Property Line ° "�- ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) r Cs 0 _ �\ w 03 1 � Q # v M r Parent material(geologic) O`ri Y'►c r�t'3�1 Depth to Bedrock Depth to Groundwater. Standing Water in Hole: /y/A Weeping from Pit Face /a Estimated Seasonal High Groundwater N/k DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: P6 Depth Observed standing in obs.hole: in. Depth to still mottles: Depth to weeping from side of obs,hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level , Adj,factor _ Adj.f3tountlwater level Observation PERCOLATION TEST Date y S �� Thue fU%� j ' Hole# I Time at 9" Depth of Perc Time at 6"` -_ Start Pre-soak Time @ °`" Time(9"-6" _ End Pre-soak Rate Minilach ti Site Suitability Assessment: Site Passed v/Site Failed: Additional Testing Needed.(Y/N) -_ Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one(1) week prior to beginning. Q:\.SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other iSurface(in.) (USDA) (Munsell Mottling (Structure,Stones;Boulders. consistency. vel A LS DEEP OBSERVATION HOLE LOG Hole# 2- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ray 4 LS 16YO,113 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell Mottling (Structure,Stones,Boulders. onsistency.%Gravel) 4 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell Mottling (Structure,Stones,Boulders. Con ' ten Flood Insurance Rate Mae: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system`/ If not,what is the depth of naturally occurring pervious material? ..-.---- Certification I certify that on �`1q (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required trainin , xpertise and experience described in 310 CMR 15.017. �� Date S 141/U Signature S , Q:\S.EPTIOPERCFORM.DOC Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 71 ANCHOR LANE Property Address Owner Owner's Name information is COTUIT required for MA 2/27/10 every page. Cdy/Town State Zip-Code de Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please.see completeness checklist at the end of the form. Important: A, General Information When filling out A forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 . Company Address CENTERVILLE MA 02632 _ - '80'" Cityrrown State Zip Code 508-420-4534 S14297 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 inspiectioi j was performed based on my training and experience in the proper function and mainterance of on~site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 o`f -n Title 5(310 CMR 15.000).The system: ,a ? w co .4. El Passes ❑ Conditionally Passes ® Fails - ❑ Needs Further Evaluation by the Local Approving Authority Val 1n rn �.n ; P hO InspegWS 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•09108 ` Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 17 4 . v' Y commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 ANCHOR LANE Property Address Owner Owner's Name information is COTUIT required for MA 2/27/10 every 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 indicate s that any of the(allure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass ins pection 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-09/08 Title 5 Official Inspection Forth: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 71 ANCHOR LANE Property Address Owner Owner's Name information is COTUIT required for MA 2/27/10 every page. Cltylrown State Zip Code Date of Inspection B. Certification (Cont.) 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 l5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 ANCHOR LANE Property Address P I Owner Owner's Name information is required for COTUIT MA 2/27/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m r pp , provided that no other failure criteria are triggered.A copy Y of the analysis must be attac hed 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 volu❑ ❑ " me is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 71 ANCHOR LANE Property Address Owner Owner's Name information is COTUIT required for MA 2/27/10 every page. Cdyfrown 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 orprivy 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) urge 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•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 L s Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 ANCHOR LANE Property Address Owner Owner's Name information is required for COTUIT MA 2/27/10 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09= 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 71 ANCHOR LANE Property Address Owner Owner's Name information is required for COTUIT MA every page. Cltyrrown 2/27/10 State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A 1000 GALLON TANK AND A 1000 GALLON LEACH PIT ACCORDING TO AS-BUILT Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail HOUSE IS VACANT Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ms 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 ANCHOR LANE Property Address Owner Owner's Name information is COTUIT required for MA every page. City/Town Date/1 State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): TANK AND PIT NO D-BOX t5ins•09108 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 71 ANCHOR LANE Property Address Owner Owner's Name information is required for COTUIT MA 2/27/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet .Material of construction: ®concrete ❑metal ❑fiberglass ❑polyethylene y ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON ACCORDING TO AS-BUILT Sludge depth: t5ins-09/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 ANCHOR LANE Property Address Owner Owner's Name information is required for COTUIT MA 2/27/10 every page. Cdyfrown State Zip Code Date of Inspection D. System Information:(cont.) Septic Tank(cont.) i Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09J08 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 10 of 17 Commonwealth of Massachusetts Efflogm Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 ANCHOR LANE Property Address Owner Owner's Name information is required for COTUIT MA every page. Clty/Town 2/27/10 State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 71 ANCHOR LANE Property Address Owner Owner's Name information is required for COTUIT MA every page. Cltyfrown 2/27/10 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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 ANCHOR LANE Property Address Owner Owner's Name information is COTUIT required for MA 2/27/10 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): PIT IS IN HYDRAULIC FAILURE Cesspools(cesspool must be pumped as part of inspection)(locat e on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09M 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 71 ANCHOR LANE Property Address Owner Owner's Name information is COTUIT required for MA 2/27/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 ANCHOR LANE Property Address Owner Owner's Name information is required for COTUIT MA 2/27/10 every page. City/Town 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 tsins•09)08 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 `< 71 ANCHOR LANE Property Address Owner Owner's Name information is COTUIT required for MA 2/27/10 every 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: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 ANCHOR LANE Property Address Owner Owner's Name information is required for COTUIT MA 2/27/10 every page. Cltyfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Mrs-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 New Page 1 Page 1 of 1 TOWN F BARNSTABLE LC�ATICiN ' � —'' SEW `�. AGE# VIL LAGS _ ®&�UkT ASSESSOR'S MAp 8c LOT INSTALLER'S NAME PHONE NO. d M SEPTIC TANK CAPACITY LEACHING FACILITY: (type) - de (size) ��V NO.OF BEDROOMS BUILDER OR OWNER PERWrDATE: C A c 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 Ric 6 o �e(I` as AA OC R g a�� AC u3 g qq 8C cj�G http://www.town.bamstable.ma.us/assessing/2010/I 4display.asp?mappar=024107&seq=1 2/27/2010 f TOWN OF BARNSTABLE <t LOCATION 7%4,niC 6V LO-4 P SEWAGE# ;ZO IQ 16-0 VILLAGE Co I-0 t ASSESSOR'S MAP�I&PARCEL INSTALLER'S NAME&PHONE NO. -Coo! SEPTIC TANK CAPACITY J= J lsxi l(l LEACHING FACILITY:(type) t0t,'f c&0e- (size) NO.OF BEDROOMS 3 - OWNER SeC;-e-4-T _p_t1In1 '-` PERMIT DATE: 5" 1 l COMPLIANCE DATE: a 40 Separation Distance Between the: See P)" Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ( ,) T 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 15e-C+- j'fVJJ 1C. i 4,7 ur 3 � o ,y^ TOWN PF BARNSTABLE I;�r ��TIGN SEWAGE # VILLAGE ` ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO., SEPTIC TANK CAPACITY LEACHING FACILITY: (type) - d (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: C r DA 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 IA Glict a �3 AA oc C q3q a G g qq� 8c �� Yr e t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS z DEPARTMENT OF ENVIRONMENTAL PROTECTION W 'f ti W �e { TITLE 5 RECEI ED OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY A SESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR JUN 04 2002 PART A CERTIFICATION TOWN OF BARNSTABLE t • °+ '' ' HEALTH DEPT. Property Address: 71 ANCHOR,LN COTUIT, MA 02635 Owner's Name: PAT RYDER (` Owner's Address: 25 WHIDAH DR E. HARWICH, MA 02645 MAP PARCEL Date of Inspection: 5/14/02 I LOT - Name of Inspector: (please print)- JOHN GRACI 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 information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and,maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Pass e's e°�' _ Conditionally Pas' s _ Needs Further luation by the Local Approving Authority Fails. Inspector's Signature: Date: 5/14/02 , i The system inspector shall submit a py of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectio . 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.sem to-the buyer, if applicable,and the approving authority. fi Notes and Comments SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. ,z. 't I Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM << PART A ' 'CERTIFICATION (continued) Property Address: 71 ANCHOR'LN COTUIT, MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02 . t Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: •k X 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: SYSTEM PASSES 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. x.. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. d`A" 20 year'"s old* or the septic tank(whether metal or not) is structurally unsound,exhibits n/a The septic tank is metal an 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 i. 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 1 ,r Page 3 of 1 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 ANCHOR LN COTUIT, MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02�t, a 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(t)(b) that the system is not functioning in a manner,whic.'fi,will protect public health,safety and the environment: cl _ Cesspool or privy is within 50'feet of a surface water _ Cesspool or privy is,wi&irn.S0 feet'of a bordering vegetated wetland or a salt marsh '4 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 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 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 t "This system passes if'the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compoun`ds'indicates'that the well is free from pollution from that facility and the presence ol'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. t,• 3. Other: n/a b Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A E CERTIFICATION(continued) Property Address: 71 ANCHOR LN COTUIT, MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02 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 nLa. 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 coliforin 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 forma (Yes/No)The system fah IRhave 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 E. Large Systems: I` 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 _ X the system is within 400 feet of a surface drinking water supply, X the system is within 00 feet of a tributary to a surface drinking water supply ! X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone II of a public water supply well If you have answered"ye's"yfo aiy"question in Section E the system is considered a significant threat, or answered "yes" in Section D above llie`large sysle`iii h,is`'fiiiled. The owner or oher.1tor of any I irEe System considered n siEnilicnnt threat under Section E or failed under'tection D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. l;CE i d Page 5 of I 1 >v. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 ANCHOR LN COTUIT, MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: •� f 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? ,i ^ .r 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 dweling'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 fi-om 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 informationJor exaraple,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 15,3+02(3)(b)], F k 1 .i d S Page 6 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 ANCHOR ON COTUIT,MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02 j '''FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):`3,, ,,Number of bedrooms(actual): 3 DESIGN flow based on 310 CMk: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, ,2,, Water meter readings, if available(last 2 years usage(gpd)):, 3 t (J 0L— Sump pump(yes or no): NO Last date of occupancy: 1/1/02 2001, 3�,vuO 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 orno): 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 L 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: 1982 IJI' ONVNER Were sewage odors detected when arriving of the site(yes or no): NO Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANCHOR LN COTUIT, MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02 BUILDING SEWER(locate on site plan) Depth below grade: 30" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance frorn private water supply well or.suction line: n/a Comments(on condition of joints, venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a ds,age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5't7'1-W 4' 1,01," 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 tj Comments(on pumping reconunendatio.ins,'inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):; n/a tt f tt. '1t 2 -W 4' Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANCHOR LN COTUIT, MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of constructiow._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: n/a Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): ` n/a PUMP CHAMBER: _(locate on site,plan)_ , x 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 ;y z - R Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: 71 ANCHOR LN COTUIT,MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02 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: nla 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 ., s;., '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. PIT WAS EMPTY AT TIME OF INSPECTION,SYSTEM SHOWS NO SIGNS OF FAILURE. BOTTOM OF PIT IS AT 8'. 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 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 4. Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANCHOR LN COTUIT,MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02. 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. ,... Q eCIL v `A v AA a 0 c �c in Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANCHOR LN COTUIT, MA 02635 Owner: PAT RYDER Date of Inspection: 5/14/02 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 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. tt ld.r\ r,A COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE' Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Q Q Property Address: 71 ANCHOR LANE COTUIT Name of Owner BOB STRAUB F Address of Owner: 49 NOXON RD.POUGHKEEPSIE N.Y.12603 F� 1 0 Date of Inspection: 2/9/99 to Name of Inspector:(Please Print)JOHN GRACI 0A lam a DEP approved system inspector pursuant to Section 15.340 of Title 5'(310 CMR 15.000) �ip9'YSr Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02536 Telephone Number: (508)564-6813 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection Is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Eval ation 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. Inspector's Signature: Date:2/10/99 The System Inspector shall ubmit 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 THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 912198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 ANCHOR LANE COTUIT Owner: BOB STRAUB Date of Inspection:2/9/99 INSPECTION SUMMARY: Check A, B, C, or D: OSYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. NQ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. NO Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced NQ The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 ANCHOR LANE COTUIT Owner: BOB STRAUB Date of Inspection:219/99 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 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla_(approximation not valid). 3) OTHER nla revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 ANCHOR LANE COTUIT . Owner: BOB STRAUB Date of Inspection:2/9/99 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 nLa. 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 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 ANCHOR LANE COTUIT Owner: BOB STRAUB Date of Inspection:2/9/99 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. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 ANCHOR LANE COTUIT Owner: BOB STRAUB Date of Inspection:219/99 r FLOW CONDITIONS RESIDENTIAI; Design flow:-Q g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):$ Total DESIGN flow: IV Number of current residents:2 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NO Last date of occupancy: Wa COMMERCIALIINDUSTRIAL Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings,if available:nla Last date of occupancy: Wa OTHER: (Describe) nta i Last date of occupancy: n(a GENERAL INFORMATION PUMPING RECORDS and source of information: NONE System pumped as part of inspection:(yes or no):NQ If yes,volume pumped n(a_ gallons Reason for pumping: nla 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: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1982 Sewage odors detected when arriving at the site:(yes or no): MO revised 9098 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANCHOR LANE COTUIT Owner: BOB STRAUB Date of Inspection:2/9/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2LE Material of construction:_ cast iron X 40 PVC 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 r (locate on site plan) Depth below grade: 2' Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa r If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): hKi ' nla 4 Dimensions: L 9'G'H 5'7"W 4'10" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: !! How dimensions were determined: 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 PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene other(explain) nLa Dimensions: nLa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:x1a Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping: nLa 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.) r , revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANCHOR LANE COTUIT Owner: BOB STRAUB Date of Inspection:219199 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) IVA Dimensions: Wa Capacity: n& gallons Design flow: n& gallons/day Alarm present: NO Alarm level:jLa_ Alarm in working order:Yes_No_ NQ Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) revised 9098 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANCHOR LANE COTUIT Owner: BOB STRAUB Date of Inspection:2/9/99 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: n/a Type: leaching pits,number: 1000 GALLON OCTAGON LEACH PIT leaching chambers,number: _nLa leaching galleries,number: ji& leaching trenches,number,length: nLa leaching fields,number,dimensions: n/a overflow cesspool,number: Wa Alternative system: n(a Name of Technology: 17La Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY PIT WAS EMPTY AT THE TIME OF THE INSPECTION NEVER MORE THAN 2'IN CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n/A Depth of solids layer: n& Depth of scum layer. n(a Dimensions of cesspool: n& Materials of construction: Wa Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection)nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 Page 9 of 11 SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANCHOR LANE COTUIT Owner: BOB STRAUB Date of Inspection:2/9/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a r a o AA a O A ac �� y DA yq revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEMS INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ANCHOR LANE COTUIT Owner: BOB STRAUB Date of Inspection:2/9/99 + NRCS Report name: n/a Soil Type: nta Typical depth to groundwater: nLa USGS Date website visited: n1a Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: , _ Obtained from Design Plans on record X 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) GROUNDWATER DETERMINED FROM USGS MAPS AND CHARTS AND VISUAL. r revised 9/2/98 Page 11 of 11 1171 L--0CATION SEWAGE PERMIT NO. L cyr Fk AAlcite-K llfm` 7 9 — 37Fr V I L L A G E INSTALLER'S NAME B ADDRESS B U I L 0 E R OR OWNER DATE - PERMIT ISSUED �-ULy ls' Ifzf DAT E COMPLIANCE ISSUED —� A�f1'aiBat�a�. a � v w "ai v. r 4AiC11 OZ 44Ai1--- 6 No.................:7 Fps....9 .5............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® .OF HEA�®LTH t Appliration for Uispvaal Worko Tomitrurtiun Famit Application is hereby made for a Permit to Construct 04 Q or Repair ( ) an Individual Sewage Disposal syst `► ..------•.........................•--••-- / Lo n Addres` Lot No. o Own ddress a T ...................................... --:�_:_--..------.. .• ... .......-•-•-------............-•----......----^--- Installer Address Type of Building Size Lot_ _M,----______Sq. feet Dwelling—No. of Bedroom, _..__.__ ____________________________Expansion Attic ( ) Garbage Grinder ( ) 4 Other—Type of Building ..... No. of persons.........6....._-------- Showers ( ) — Cafeteria ( ) Q' Other fixtu es ----------------------- ------------------------------------------------------------------------------------------------------------------------ d DesignFlow......... _ ._ gallons per person per day. Total dailyflow........?��... ....................gallons. WSeptic Tank—Liquid capacity/P _gallons Length. ........__._ Width. ® ."'__ Diameter................ Depth................ x Disposal Trench—N$. -------------------- Width.................... Total Length._._`._` __ Total leaching area............... sq. ft. Seepage Pit No........I...._.__.. Diameter.... `.._....... Depth below inlet.._ __s�__..__.. Total leaching area.j. ._sq. ft. Z Other Distribution box Dosing ank ( ) ®4 ' _.. ------------ Date___ Percolation Test Results Performed by.._ �. _._._.. ___�_. �-g�• aTest Pit No. 1-•-•-------•----minutes per inch Depth of Test Pit-------------------- Depth to groun water _GCS% fT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..&._.. R+ •---•---•--•-•---------------------------------•----•---------------------------•---......_._._..---......................................................... 0 Description of Soil �f ••=••---. txj _•-------------------•-•--•-------- ---�'- - - -- _.. ._..._... ----------------------------------------------------•--------------------------------------------------------------------------------------------...................................................... 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 iITL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board#f health. g / Date Application Approved BY------ �\ ----------- .....-0-�=�-� --� ��' Date Application Disapproved for the following reasons-...................................................-.......................................................... _ --------------------------------------------•---------------..........-----...--•-------•--•--------...--------............--•--••----•-------•--------•--------------•------••------------------------ / Date ------. Issued.....Permit No...............•----••••-•.........••-•-••--••••• f �Z S 7 - -•--...- -•------------------f------------- Daze THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application'is or Repair an Individual Sewage Disposal ....Ai4e-, ............................................................................... System at:'A Owner- ddress xIns .' � ----ller Address Type m6Building Size Lot_ feet � Dwelling—No. of Bedro Garbage Grinder Other—Type of Building ZkMnliert..... No. of persons......... --_---------- Showers Cafeteria Other fixtures . �7 Design Flow 1:4 Septic Tank—� Liquid ................ � Disposal Trench--N8 .................... vv .................... TotmLcogzu--'--' Total leaching area. f t. Seepage Pit Nu__/--------- .......... Depth below Total f t. Z Other Distribution box Dosing 0-4 Percolu600Test Results Performed '��?.........-----' . Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground Test Pb No. 2................minutes per inch Depth of Test PiL--------. Depth to orouod.vvatcr-^/*/..x��' u� ---_'_------.-----_---_'_____-_---'---'-'_-'------_---'_---------------- 0 Description of Soil. ..................................-.................................................................................................................................................................... �4 -'-----'--_.-.._'----'-_----_-----__'_-_._----_----'-_'__.__--_-----------'--'---_ U Nature c6 Repairs or Alterations--Answer when ------.---.---------.----._---__-________ -----_--------'__-__'-'__--__'_-_--'-_____'-__'_'------.---.---_.---.__---'------'-_--'-_ Agreement: . The undersigned agrees to instal} the aforedmccibed Individual Sewage Disposal System in accordance with the provisions of TIT 1G 5nf the State Sanitary Code-- The undersigned further agrees not toplace the system io operation nob} u Certificate of Compliance has been issued by the board of health. ----.---_-.� 'c~, ate Application ApprovedD]�-------./..;�-��-�~-'^��«� - ----- --' ��.^-�y---'---''��' DateA�Vrication Disapproved for the following reasons:.............................................................................................................. / o�" P�zo� � � i BOARD OF HEALTH THIS IS TO CEJRTIF'V, That,the-lidividual Sewage Disposal System constructed (X or Repaired by....;?....z.. ...............'... ..................N.!;: ................................................... has been installed in accordanc'��,with the Date rovisibil �of T o�_ f-),of The State Sanitary Code as described in the upp/u�000nnuisyuxa vvoruu � THE ISSUANCE OF THIS CERTIFICATE SHAL;ANOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 7.nTIO T1.,SF CTORY. -- � - �. �spector ' ^ ~, r � T*� co��omvxs�cr*"�� mAeswoHusErrs � . BOARD OF HEALTH ! ,x31NYM '+� "� { ' S.•Nl&; v'i 4 .� w ; V1y' 41 3 , }y�e• y Jr -`" At4 r��.wsN GrAD��7L• - F�NtSM �Qs1�� NatYN G?tRn[* • _- _--�� 0 vEA Tit N 40 , td'✓.s ,� � . • '� ; �� _ �.��,��±�► ,'�1; ;'Sate,�iti,�+,;��yd%=v��.,;;n,�„r�+- _ '4 w"1'. • r--•.a.r:•_ .�._.,.:..._� �.r.ti......�. \Yi-. `..c�'• . . 11 tee: .t"."" etint.! �GK F aH�dL14.IAl P - � �__ _.. �!• � �j „a!_�G� �~ �� 3 Pfif3To h'6 ! L L j ek w `F t h I .x i t..iYw u.9 _'r.i•+---.-.�+rrw_t„I._. J ` , f .� G.Qv$*40rA> Srio.✓Q --"...-^-•� \ � • -°.,�.—.�',',,~.'¢;-,�!..._ ,-:.--�,A-�_rC_'�.,..R...r-:_ � �' � � 't �S' � � � � G � ! • f j 1lk a i Tr •4't 1 4 m c c P I • •.rte �ti 14 TWA A# y AV 0~0100,ftf.* .41 k pr Ir y I ep� \ ti. j °• 4 j h .SR �ci•� fi iA'�cH•,.rG .fl� r 1 �� 1 • PrlbPc�.�E�D.SI��o�.�C�'�isv�'v��+oL 017 Aga srts ,y► r"�cu .a.� r•�►Ra_ r7v_ A4�u ry ,1� 'O�'d9,t'l� �,R!t STAZL.E cCdT- ►c r ` . MAC . Ate` Z i`1�N�N. /V1.1 T�'�{% • TL i '� ,S:? �f� LF ., r` C +, • ,W � � ?� f t � � Tu1�,gF' f�? ..S'N�`-r�� L h ,, `7lt+!� t�f`, )C�•'" ,•.........-..,.w .._._- _.__..._._ ,.,.._ w ACCESS COVERS MUST BE WITHIN INSPECTION 9" MINIMUM. INVERT ELEVATIONS : DES I GN CR I TER I A : GENERAL NO TES 6" OF FINISH GRADE PORT 3 ' MAXIMUM COVER FIRST 2 ' TO INVERT OUT SEPTIC TANK: 100.5 DESIGN FLOW: BE LEVEL INVERT IN DIST. BOX: 100.37 3 BEDROOMS AT 1 /0 G.P.D. PER I . THIS PLAN /S FOR THE DESIGN AND CONSTRUCTION f INVERT DUT D!ST. BOX: I00.Z BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE D/SPOSAL SYSTEM ONL Y. t' D/AM PI _ CLEAN SAND BACKFILL INVERT /N LEACH CHAMBER: 99.91 ��- AROUND AND 2' OVER CHAMBERS BOTTOM OF LEACH CHAMBER: 99.0 NO GARBAGE GRINDER 2. VERTICAL DATUM /S ASSUMED. FOR BENCH MARKS l00.5 l00.2 / l - SET. SEE SITE PLAN. GAS 100. 37 37 -p gg•g! ADJUSTED GROUND WA TER: N/A BAFFLE SEPTIC TANK REQUIRED: l0 HIGH CAPACITY INFILTRATOR OBSERVED GROUND WATER: N/A 3 OUTLET 330 G.P.D. X 200x - 660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND EXISTING D-BOX CHAMBERS /N TRENCH FORMATION BOTTOM OF TEST HOLE #l : 92.3 SEPTIC TANK PROVIDED: 1000 GAL EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL I000 GAL SEPTIC TANK b" CRUSHED STONE OR CONFORM TO MASS. D.E.P. T/ TL E 5 AND LOCAL SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DESIGN PERC RATE ! 5 MIN/INCH PROF I L E : NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOAD/NG RA TE - 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER r 330 GPD / 0. 74 GPD/SF - 446 S.F. REQUIRED THAN 3 ' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: 10 HIGH CAPACITY INFILTRATOR CHAMBERS /N A TRENCH 62.5 LF x 7. 79 SF/LF 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR 487 SF x . 74 GPD/SF - 360 GPD APPROVED EQUAL. 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED SOIL TES T P I T DA TA s PRECAST CONCRETE AND WATERTIGHT. D-BOX SHALL l ND I CA TES I NO l CA TES BE WATER TESTED TO CHECK FOR LEVEL WHEN THERE PERCOLATION OBSERVED IS MORE THAN ONE OUTLET. r. TEST - GROUNDWATER 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE TP s/ Pf12882 TP •2 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. !� 0" t02.8 0" l02.8 HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR FOR LOCATION OF UNDERGROUND UTILITIES. 0 A LOAMY IOYR H^ LOAMY IOYR 8. EXISTING LEACH PI T TO BE PUMPED DRY AND � SAND 3/3 SAND 3/3 2`2 pp' BACKF!L L ED. 5- .................... 102.4 6- ........ _. ... ..... 102. 3 p LOT 88 20. 607' S. F. s p LOAMY IOYR p LOAMY IOYR SAND 5/6 D SAND 5/6 o 30' ......... _. .. ......... l 00.3 28- _. _ 100. 5 0 o C MED-COARSE IOYR C , MED-COARSE IOYR o SAND 6/6 SAND 6/6 F 44- BM. CORNER OF BULKHEAD EL-IOJ.JB ^� �G CB/OH FAD Z $ace �/ NO WATER NO WATER spy 126- 92. 3 /20- 92.8 o EXISTING OL DATE: MARCH 26. 2010 SEPTIC TANK ^ Qp TEST BY: STEPHEN HAAS CB/DH FAO WITNESSED BY: DAVID STANTON PERC RATE: l 2 MIN/INCH vp D-BOX 9 SyFO o I ^ ® CATCH/BAS I N ti p. , I Z � P02 oZ c.y U TPe I U CB/DH FND a0 U� SE � 7- / C SYSTE/VI DES / G/V 10 HIGH CAPACITY� v,� / INFILTRATOR CHAMBERS IN TRENCH FORMATION /� 0'9� tJ 7 / A /VC/--FOR LA /VE . MAP 24 . PARCE : _ / 07 BA R /VS TA SL E rCoTu / T > MA . CB/DH FNO PREP,4 RED FOR 9, LEGEND 1 SC,4 / 20 MA Y 19 . 20 / 0 � • �V ■ CB CONCRETE BOUND -W WATER L/NE ' / O HYDRANT EAGLE SURVEY I NG I NC LOCUS O O -G GAS L/NE OHW- OVER HEAD WIRES �. 923 Route 6A LIGHT POST / \� •.r � � ` Ya rmou t hipo r t MA 02675 -E- UNDERGROUND ELECTRIC LINE // �l\�� 5 O 8 3 6 2-8 1 3 2 -T- UNDERGROUND TELEPHONE LINE �� %�\ /' �` 5 O 8 4 3 2-5 3 3 3 -CTV- UNDERGROUND CABLEV/S/ON LINE + 40.4 ..SPOT ELEVATION -40- EXISTING CONTOUR 4Q - PROPOSFD , n.NT0Ui? JOB NO: !0-036 FIELD: CFW/RPM CAL C: SAH/CFW CHECK: CFW DRN: SAH �Y a.