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HomeMy WebLinkAbout0108 BAY ROAD - Health 108 BAY RD, COTUIT A=007-022 c� No. OW I 0 1103 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliCation for Disposal 6pBtrm Cutttructiun permit �s Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System idividual Compons Location Address or Lot No. ��Zr.-Y TL J L4ut� Owner's Name,Address,and Tel.No. v Assessor's Map/Parcel Installer's Nara,Address,and Tel.No.S p��&c l(�bple Gl Designer's Name,Address,and Tel.No. S cc,kt YatMov`N— � �Mt Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank &j^V Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Q-0 pxrc R \Csows<- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ealth. Si Date Application Approved by Date 3 f Application Disapproved by Date for the following reasons Permit No. 90%12.-0� Date Issued , No. �( Cam' Fee 7� F ._ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye : 01pplication for Misposal 6pstem Construction i3ermit A, r_ Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System dividual Components Location Address or Lot No. ��zc,-f I�L J GAV A Owner's Name,Address,and Tel.No. r Assessor's Map/Parcel 0 C)- r0a,a, Installer's Name,Address,and Tel.No. S0t/0\C1 4 Dtvh Designer's Name,Address,and Tel.No. **i Scot «� 1 Yc.tr^6vk-- Mt Type of Building: i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date 4 Title 3. Size of Septic Tank e X's S mac, �s/�LType of S.A.S. i 1 Description of Soil # Nature of Repairs or Alterations(Answer when applicable) QQ \ t R i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. r Signe Date 3 0 13 '1 Application Approved by , Date Application Disapproved by Date for the following reasons Permit No. P /7,o& �2 Date Issued f 4 ` . _________________________________________ , THE COMMONWEALTH OF MASSACHUSETTS -1 BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓� Upgraded( ) Abandoned( )by , C_c,,�A. t -cjz-NVf at ��� �c,� t?<S (��VAh has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. `U 6 dated Installer��rN\A rtA/-�-� Designer #bedrooms Approved design flow �, gpd The issuance of this permit hall not-bbe construed as a guarantee that the system will fiinct as designed. f / Inspector Date ° "� ----------------------------------------------- ------------------- No. ; W °� 3 Fee ;7 THE COMMONWEALTH OF MASSACHUSETTS �.� PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS C t Misposal 6p-stem Construction Permit Permission is hereby granted to Construct( ) Repair( i/l' Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe it. Date ?7 3/� / Approved by TOWN OF BARNSTABLE LOCATION Q SEWAGE# �Q n n _ o ,! VILLAGE ` ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. b r h I'll M a S� Oo�S SEPTIC TANK CAPACITY ZC( 1 G b r) g^l O LEACHING FACILITY.(type) L 1 (size) NO.OF BEDROOMS � OWNER .f PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �� i J � K Q a 013' t T WN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 4M LEACHING FACILITY: (type) ,B-�J''� � (size) eO�� NO.OF BEDROOMS' -0 BUILDER OR OWNER PERMITDATE: COMP IANCE DATE: i 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 etlands exist • within 300 f t f leac 'ng facility) Feet Furnished b r , 110 yi t� 'Tbv-IN OF BAR.NSTABLE EWAGIR VILLAGE �Of� ASSESSORS MAP&LOT j INSTALS-ER'S NAME&PHONE NO.. S8PTIC TANKCAPACITY /dD"o LEACHING FACIt.rff, (typ$) r �' NO,OF'BEDROOMS_„_ 3 _... I BUILDER OR OWNER. PERMIT®ATE:__ _ ,CC3WL ANCE DATE: p Se amdon Distance Between the; Maximum Adjusted Groundwater Table to the Bottom of Leaching Facili ty Eee'' Private Water Supply Wl.aud Leaching Facility (If nay wells exist on site or within 200 feet-of leachins facility) Edge of Wedand and Leaching Facility(If any wetlands exist sbirhiea 3Q1 feet pfcbing faci ` FuriVshad by i I" �l 77 L v � "i , 1 • O L✓ ✓1 Commonwealth of Massachusetts F Title 5 Official Inspection Form,.-, . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-'*t-`s . 108 Bay Rd Property Address Patricia Howes i Owner Owner's.Name information is required for every Cotuit. ? i - MA 02635 11-15-12 _ page. City/Town ", _ State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A..General Information„ 1. Inspector: ` Shawn'Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr 4 Company Address E. Falmouth -MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification t, I certify that I have personally inspected the sewage disposal system at this address and that the information reported below.is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience.in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000).The system: - ,. ® ,Passes ❑ -Conditionally Passes r ❑ Fails ❑ Needs Further.Evaluation by the_Local,Approving Authority r - Inspector's Signatur 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•11/10 TitleVI .nrm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts r 52 Title 5 Official inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 108 Bay Rd Property Address Patricia Howes Owner Owner's Name information is required for every Cotuit MA 02635 11-15-12 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: s ® 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 is in good working order with no sign of failure. f A B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. , Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N A ❑ ND (Explain below): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 { , t Commonwealth of Massachusetts Title 5 Official .Inspection Form ' !' Subsurface Sewage Disposal System'Form -.Not for Voluntary Assessments 4, 108 Bay Rd Property Address Patricia Howes - Owner Owner's Name information is 1. required for every Cotuit MA 02635 11-15-12 page. Cityrrown -•,, 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): '' ❑ M r broken pipe(s) are'replaced ❑ Y ❑ N ' ❑ ND (Explain below): f ❑ 'obstruction is removed rY 0 Y ❑ N' _❑ ND (Explain below): ❑ distribution box is leveled or`replaced ❑''.Y, ❑ N ❑ ND (Explain below): s ❑ 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): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is,Required by the Board of-Health: rt - El 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 p`ass'unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning{n a manner which will protect public health, safety and the environment: w , ❑ Cesspool or privy is within 5-0 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Officiai Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Bay Rd Property Address Patricia Howes Owner Owner's Name information is required for every Cotuit MA 02635 11-15-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: , ❑ The system has a septic tank and soil.absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is.less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed.at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: ' D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ' ® than 1/2 day flow t5ins-11/10 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 108'Bay Rd Property Address Patricia Howes Owner Owner's Name information is required for every Cotuit MA 02635 11-15-12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) f Yes No ❑ ® Required pumping more than 4 times in the last.year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ F E Any portion of the SAS; cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 1. ❑ ® Anyportion 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 feetpbut greater than 50 feet from a private water supply well witli no acceptable water quality analysis. [This system passes if,the well water analysis, performed at a DEP certified laboratory,for fecal colifonn 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- 101000gpd. 'The system fails. I have.determined that one or more of the above failure. ❑ ® criteria exist as described in 310.CMR 15.303,therefore the system fails. The .system owner should contact the Board of Health to determine what will be _ necessary„to correct the failure: E) Large Systems: To be considered a'large system the system must serve a facility with a design flow of.10,000 gpd to 15,000 gpd. , i 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 a . ❑. ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108.Bay Rd Property Address Patricia Howes Owner Owner's Name information is Cotuit MA 02635 11-15-12 required for 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: 9 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? El available 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts -. 6•. Title 5 Official Inspection- Form im o Subsurface Sewage Disposal System,Form Not for Vol untary.Assessments - 108 Bay Rd Property Address Patricia Howes Owner Owner's Name - Cotuit G MA 02635 11-15-12 . information is required for every �' page. City/Town r state Zip Code Date of:lnspection D. System Information ' Description: } Number of current residents: t 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? A ;r,;' ❑ Yes ® No Seasonal use? - •a ' . , ® Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): .. Detail: Sump pump? . El Yes ® No Last date of occupancy: 10-2012 Date Commercial/Industrial Flow Conditions: Type of Establishment: . 1 Design,flow(based on 310 CMR 15`203): Gallons per day(gpd) s,Basis of design flow(seats/per"sons/sq.ft., etc): Grease,trap,present? ❑ Yes ❑ No Industrial waste holding tank-present? ❑ -Yes ❑ No Non-sanitary'waste discharged to the Title 5 system? ,. . ❑ Yes ❑ No Water meter readings,.if available:. t5ins•11/10 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 ' Commonwealth of Massachusetts Title 5 Official inspection Form o Subsurface Sewage Disposal System Form Not forVoluntary Assessments ,6 108 Bay Rd Y 7M - 5 Property Address . Patricia Howes Owner Owner's Name information is required for every Cotuit MA 02635 11-15-12 page. City/Town State Zip Code Date of Inspection D. System.Information (cont.) F Last date of occupancy/use: - Date Other(describe below): r General Information Pumping Records: Source of Yinformation: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: . gallons a� How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool , El Overflow cesspool . ❑ Privy i ❑ , �, 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. - Y` ❑ Other(describe): �, • t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 108 Bay Rd Property Address ,• , Patricia Howes Owner Owner's Name';r information is Cotuit MA 02635 11-15-12' required for every page. City/Town w :'�s State -Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known) and source of information: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No e Y Building Sewer(locate on site plan):-' Depth below grade: a ,: ,. 48!! 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.): Good condition. v • _ r Septic Tank(locate on site plan): r- , 4011 Depth below grade: feet Material of construction: ® concrete . ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)'— ❑ Yes ❑ No al r • - - , Dimensions: 1000 gal ' 12" Sludge depth: t5ins-11110 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 9 of 17 ' s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 108 Bay Rd Property Address Patricia Howes Owner Owner's Name information is required for every Cotuit MA 02635 11-15-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 108 Bay Rd Property Address Patricia Howes Owner Owner's Name information is required for every Cotuit ,MA 02635 11-15-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ,: Comments'(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): * a4 Tight or Holding Tank (tank must be pumped,at time of inspection) pocate on site plan):; Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ' Capacity: gallons F 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•11/10 Tide 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 108 Bay Rd Property Address Patricia Howes Owner Owner's Name information is required for every Cotuit MA 02635 11-15-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Bay Rd Property Address Patricia Howes Owner Owner's Name information is "r required for every. Cotuit MA 02635 11-15-12 page. City/Town State Zip Code Date of,lnspection D. System Information (cont.), Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: J - ❑ leaching trenches S number, length: e ❑ leaching fields number,dimensions: ❑ overflow cesspool number: x , ❑ innovative/alternative system - Type/name of technology: Comments (note condition of soil,-signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leach pit in good condition and empty at inspection with stain line at 24" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ' ❑ Yes ❑ No t5ins-11/10 ; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Bay Rd Property Address Patricia Howes Owner Owner's Name information is required for every Cotuit MA 02635 11-15-12 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.): r i , 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•11110 a• 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 M 108 Bay Rd Property Address Patricia Howes r„ Owner Owner's Name information is required for every Cotuit' - sue" MA 02635 11-15-12,, . 16, page. City/To/Town. State Zip Code Date of Inspection D. System Information (cont.) r 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 e 1 t5ins-11/10 r 3l 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 108 Bay Rd Property Address Patricia Howes Owner Owner's Name information is required for every Cotuit MA 02635 11-15-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water , ❑ Check cellar Shallow wells I Estimated depth to high ground water: 20 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: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Common wealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 108 Bay Rd ' Property Address Patricia Howes Owner Owner's Name information is required for every Cotuit MA 02635 11-15-12 page. City/Town Stater 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 w r s t5ins-11110 Title 5 Official Inspection Form:Subsurface Swage Disposal System-Page 17 of 17 FP 11 1 00 DATE - ; -- / /----- ' PROPERTY ADDRESS; 0$^ Bay Road — .------------ ----------------- On the above date, I Inspected the septlo system at the above address. This system conslsts of the followings 1 . 1 -1000 gal.lon septic tank. 2 . 1 -distribution box. 3 . 1 -1000 gallon precast leaching pit. Based on my Inspection, I certify the following condltlons: 4 . This is a title five septic system. ( 78 Code ) 5 . The septic system is in proper working order 00 o at the present time. I SIGNATURE: ./ Name :_ .M.os.smtttr___r-------- Company; Joae2h_t. Hacomber_b Son , Inc . Add ress : 8ox�66___- ---- __CentsrvilleI_ Na__02632-0066 08-775 � 378 THIS CERTIFICATION GOES NOT CONSITITUTI3 A GUARANTY OR WARRANTY a JOSEPH P. MACOMBER & SON, INC, Tank I•Ceispools•LeachfIsIds Pumped 4, Installed Town Sewer Connections P.O. Box 66 Centervllle, MA 02632.0066775.3338 775.6412 rrep r ' � r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENvIR.ONMFENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (817) 292.6600 TRLDYCORE 3ocrrtary ARGEO PAUL CELLUCCI DAV)D B. STRU}{S Commuatoner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM WSP£CTION FORM PART A CERTIFICATION 1 08 BayRd Nam.of owTw Craig Flemming Property Address: Road Address of Owns: Cotuit,Mass. 02635 Darts of VapsiJoseph P. Macomber Jr. Narr+e of hsprctw: (P'taase Py(nt) am a DEP aPPraved systwm VaPOcta pur"-'Tt to Section I5.W of ThS. 5(310 CMR 15.000) c,m0,,yk,,e; Joseh P. Macomber & Son , Inc. -n evie 632 „g A�„ ,; o e 38 0066 T"ophorr IlursDe, _ _ CERT1FiCAMN ILA_TVA ENT 1 cerVty that I have personally Inspected the sewage disposal system at this address and that the information reported below Is true, accurst• and complete as of the time of Inspection. The Inspection was performed based on my tralning and experlenoe In the proper function and maintenence 01 on•site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the local Approving Authority Fails D.u: vupect 'q"ts' on report to the Approving Authority (Board of Health or DEPlwtthin tturTY (30) days of i e co of this Inspect) p m inspector hall subm t copy caner co System D n the system o s Y completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greats(,the Inspector � y rhali submit the (sport to the appropriate regional otflcv of the Department oK-nWonMsr%t*Protection. The original should be sent IQ VW system owner and copies sent to the buyer, If applicable, and the approving authority, NOTES AND COMMENTS Page 1 of II revised 9/2/98 ur, ►nntW on Rscycted(,per • SU*SUMACS SEWAGE DUPOSAL SYSTEM N3KCTtON FORM PANT A CFRTUICAMN toondf`U" 108 Bay Road Cotuit,Mass. o.....r Craig Flemming Dwco o+b�:1 1 /1 /0 0 ►ut£CT10N SVuUAAYt Ch.-k .4. B, C, of D* A S Y STE7J ►A.S S ES, .�.__ -' I have not found any Information wNch IndJcates that any of the faUure condtdons described In 310 CMR 1a.30J exist_ Any 1% crtteria nol cvaJuated we In4csud below, CO 111LENT3; S. SYSTDA CONDMON-k LY PASSES: 10 One or more syetsm components u described In the •Condt" ►ass' soodon need to be replaced a repaired. Tho syetam, compt@don of the replacement or repair, u approved by the hoard of HeaJth, wW pass, oo. if tndcate yI i;: o or not The eepdeNnod tsnh I YMOW, urJeecDthe owner a opacta has provided the sty tem{nap9oto�rewhh o oopY of+c C.rv�tul �J Compuence (•nachod)u+dc•dnp that the t..rtk was Irut&Uod wlWA twenty(20) Ycc+e pr4ot to the d+ta of ow wp.cv 04 lallureit Imminent. The system wW pace maps don 1 the aixJ S1np epde tank Ivroplosed with c comptlM�v c w approved by the $card of Ho& h. k or breakout or high static water levol observed In the distribution box Is duo to broken or ob#Vvcud c Sewaoe bac up Uon If (wrth approvsJ of the $oard ins c o stem willP4,4141D or dve to a broken, eetded or v nwsn dl sVlbution box. The ey HsaJth). broken pips(&) we roplacod obawcdon Is romdvod dJavibudon box I levelled w replaced AID • The synom loq,-*ed pwm,*V-mm tttan'1ow'dr^oo v"ardus to broKenw obttivolod Ops(s). The vyrtwm ww—v— InspecUon If(with opp(ovd of the $owd o1 Hoalth)t broken pips($) we roplaeid obswcdon Is removed 1 of 11 revised 9/2/98 hie V SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPEC'nON FORM � PART A CERTIFICATION (contirx►ed) PropertyAddraas: 108 Bay Road Cotuit,Mass. Owrw: Richard Flemming 0ou of t„ao«tsw+. 1 1 /1 /0 0 C. FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: lO_ Condrdons a:Iat which require further evaluation by the Board of Health In order to determine'lf the system 16 ftmn9 10 protect V- public health, safety and the snvtronment, 1) SYSTDA WILL PASS UNLESS BOARD OF HEALTH DET13tMINES W ACCORDANCE WITH 310 CUR 15,303(1)(b)THAT rKE SYSTEM a NOT FIJNC71ONW0 W A MANNER WHICKYALL.PROXECT THE PVBUC UEALTVLAND SAFM AX0 THE E)AaBOkMS L Alice Cesspool of privy Is within 60 feet of surface water Cesspool of privy is within 60 feet of a bordering vegetated wetland of a %all marsh, 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)Dr:T1>RMOl3 THAT THE SYSTBs CS FUNCTIONw0 IN A WANNEA THAT PROTECTS THE PUBLIC HEALTPf AND SAFM AND THE 94WONMEXT: The system has a septic tank and loll absorption system (SAS) end the SAS Is wlthln 100 het of a wrfece wets( wpply of tributary to t. wrfsca water supply. UQ The system has a ►split tank and loll absorption system end the SAS Is wlthln a Zone I of a pvWc water wpp1Y wou �]1 The system has • septic tank and poll •bsorpOon system and the 3A3 Is within 60 feet of • private wets' wp•pfy way. �1Jt The system has a septic tank and ►oil •bsorptlon system and the 3A3 Is less then 100 het but 60 feet or mo+s ho'*+ • private wale, supply will, unless a well water analysis for collform bsctsfta and volsd organic le compound+ Inciluus trot tr�a li wall Is lrae hom pollvdon from that facility and th@••prsa nca'of tammonis Ntrogen and Nuste nluogen Is eQuar to o+ isss than 5 ppm. Method used to determine distance lr�y', (&WozJm#on not vatlld).- 71 OTHER revised 9/2/98 Paile3of It 4 1 SUBSURFACE SEWAGE DISPOSAL SYSTE)d WSP£CT10N FORM PART A CERTIFICATION (con wad) PrcgartyAddreee: 108 Bay Road Cotuit,Mass. own«: Craig Flemming_ Deta Of y,w.cdon: 1 1 /1 /0 0 D. SYSTEM FAILS: You must Indicate either 'Yes' or 'No' to each of the following: _ I hew determined that one of w. The`Board of he lowing faiure of H althlshouldnbedcontacted to deteons oxlgt as r(min Iwhatt will be necessary to cones ow t441 determinatlon Is Identified below. Yes No / oornpor>•rtt•do•'to ertt overiw�dad orciag4� SAS Of CNi �•-' - y Backup of Nw•g•Irrw 4*clAty .VT*f�^ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded a do99e0 SAS or cesspool. Static Iiquld,level_In_the.dls ributlon box above outlet Invert due to an overlwded or slogged SAS or eesepooi. ��_ 'Vr�/,,, ¢r Liquid Oepth tn.ta++Voa'li lisi than 6' below Invert or available volume Is lean than 112 day flow. --- / due to clogged or obstructed plpe($). Required pumping more thab4 times In the last year KO Number of times pumped —. Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. wpply or tributary to a surface water wpWr Any portion of • cesspool or privy le within 100 feet of a surface water (� Any portion of a cesspool or.prlvy le•wlthin a Zone I of a public well. Any portion of s cesspool or privy Is within 60 last of a private water suPPly well. G� Any portion of a cesspool or privy Is Ise*•than 100 fast but greater then 60 feet from a private water alePiY •+t ''�' '- acceptable water quality analysis. If thou cis,well has been an&lyzed o ammonla nlu gent e andnluat• nitrogen.ach copy of wellw water anarr+ + -colllorm bacteria, volatile organio•compo E. URGE SYSTUA FAILS: You must Indicate either 'Yes' or 'No' largetachofshelf ollowinn to the criteria above: The following criteria applysystems The system serves a facility environment design flow Of 10, 00 ceu�one oOmorepolthe lolltowinger reondltlon ge )�zlet;and�• system If • s1prJAcant weer t health and salety and the Yes No / 4•/ the sYstenm Is within 400 last of • surface drinking water euDDIY -' er -te.0 eurlaoa�►kJ�I•'fT'""asar+u►fIY d•� the systemlrwlt� 200 pod Zo�+e �� of fret Of+ 't Y �th• system Is located In a nitrogen sensitive area(Interim Wellhead Protection Area.IWPA) Or a maP • -' water supply wall) ' shall upgrade the system In accordance with 310 CM `* p R 16.704(2). Please cons`* Iota+ r The owner or operator of any such system oMcs of the Department for further Inlorration. Pstr{of I1 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART B CHECKU3T P►opanyAdbeas: 108 Bay Road Cotuit,Mass. ownw: Craig Flemming Date of Inspectson. 1 1 /1 /0 0 Check If the following have been dons: You must Indicate either 'Yes"or 'No' as to each of the following: Yes No Pumping Information was provided by the owner, occupant, or Board of Health. None of the a y s t s m c on4kwwnU la&we:b&m pawtpad►boa.atJ e.aat iwo•w oaica e++d the 1Yetesn haabe as vwcelaaq.w.d !' rates during that period. Large volumes of water have not been Introduced Into the eyatem recently or as pan of we Inspection. 4,1 As built plans have been obtained and exemined. Note If they era not available with N/A. _ The facility or dwelling was Inspected for signs of sewage backup. The system does not receive non•sartltary or Industrial waste flow. _ The she was Inspected for signs of breakout. 4 _ All system component..�Iuding the 3oll Absorption System, hive been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inapected for condition of oei or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The else and location of the Soil Absorption System onthe all, has been determined be"d on: Existing Information. For example, Plan at B.O.H. _ Determined In the field (If any of the failure criteria related to Pert C Is at Issue, approximation of distance Is vmcceptat: 116.J0213I1b11 The facility ownu La W-ocr-T 1-,Jf dltiarant frnal nu.ou),wrarw;rauldad,wLth)c ar—loaon ifs- ^at SubSurface Disposal Systems. revised 9/2/99 of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM . PART C SYSTEM INFORMATION P,opsrtyAddro": 108 Bay Road Cotuit,Mass. Owner: Craig Flemming Dow of Edon:1 1 /1 /0 0 FLOW CONDMONS RESIDENTIAL: OosJgn flow:a_g•p•d•roedrq m. Number of bedrooms (design): umber of bedrooms(actual):„�' • Total DESIGN flow 11lq= -e4 Number of current residents: Garbage grinder(yes or no): ' Laundry (separate system) LY�0,�s or�):_: If yes, sspacaLaJnspoct on.requlred —. Laundry system Inspected(Voyor no) Seasonal use (yes or no): �-S Wrier moist readings.If available (last two year's usage(gpd): IJA41 I,/WFQI'_ Sump Pump (yes or no):..dT _ Lost dots of occupancy Al-1-J7> If well has not been tested 'in the last 12 months_ . It,-- COMMENC%ALJPJDUSTRIAI: should be done now! Type of esubllshment: See pages 6A & 6B/ Design flow: ' a pg d ( B+sod on 16.203) _ Basis of design flow Grosse trop present: (yes or no) Indus0al Waste Molding Tank present: (yes or n0).42' Non•sonitary waste discharged to the Title 6 system: (yes or n )� _ Water moist readings, If available: Lost date of occupancy: -4�0` OTHER:(Describe) ZA Last date of occupancy: ) • GENERAL INFORMATION pUMPWQ RECORDS and source of Information: System pumped as put of Inspection: (yes or no)_ If yes, volume pumped: -;-' gallons Reason for pumping: TYPE OF SYSTEM __._mil Septic tank/distribution box/soil absorptJon system Single cesspool &0 Overflow cesspool Privy Shared system(yes or no) (it yes, sttach previous Inspection records.If any) I/A Technology sic. Ansch copy of up to date operation and maintenance contract Tight Tank _Copy of DEP Approval Other APPROXIMATE AGE of all components, date InstallediJf known)-and aourae of•Jvsfo+,n+don: Sq,w"odor detected when arriving at the site: (yes or no) I revised 9/2/98 Pses6of 11 BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT Of a�a P.O. BOX 427 ysa SUPERIOR COURT HOUSE BARNSTABLE, MASSACHUSETTS 02630 PHONE: 362-251 ' EXT. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sample wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. It is recommended to use a straight faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not till bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper) is $25.00. Checks should be made payable to Barnstable County. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information. 7. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday 8:00 AM to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Completion of tests and results takes 7-10 business days. Results will be sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM are available for an additional charge. Contact the laboratory for availability. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DTFFERENT LOCATIONS THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS ACCURATELY PERFORMED. PLEASE COMPLETE REVERSE SIDE OF FORM I PRIVATE WELL WATER SAMPLE DATA COLLECTION SHEET VOC VIAL NUMBERS FIELD BLA14K BOTTLE ID I1Ut•1BER DATE REC ' D NAME COLLECTION DATE MAILING ADDRESS COLLECTION TIME WELL DEPTH 'STREET ADDRESS YEAR WELL INSTALLED MAP/PARCEL TELEPHONE COLLECTED BY : SAMPLE APPOINTMENT NEEDED ? REASON FOR TESTING : ( ) SUSPECT A PROBLEM (EXPLAIN) ( ) REQUIRED ( ) FOR INFORMATION ONLY ( ) NEW WELL ( . ) REAL ESTATE TRANSACTION ( ) OTHER (EXPLAIN) DISTANCE OF WELL FROM POSSIBLE CONTAMINATION SOURCES (IN FEET) : SEPTIC TANK\CESSPOOL FARM SALTED ROAD UST LANDFILL INDUSTRY GAS STATION OTHER TREATMENT USED: ( ) NONE ( ) WATER SOFTENER ( ) FILTER; SAMPLE TAKEN BEFORE/AFTER TREATMENT (CIRCLE) ***************************************************************** RESULTS VOC ROUTINE CHLOROFORM ( TOTAL COLIFORM\100 ML 1, 1 , 1 TRICHLOROETHANE (PPB) PH CONDUCTIVITY IRON (PPM) NITRATE-NITROGEN (PPM) SODIUM (PPM) COPPER (PPM) 0 ANALYSIS. DATE:_ ANALYSIS DATE: i SUBSURFACE SEWAGE DISPOSACSYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(comkwed) Pr,q,wTy A61ei,1 08 Bay Road Cotuit,Mass. Owrw: Craig Flemming D—of lnspecdors:1 1 /1 /0 0 BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction: cast Iron�VC�othsr (explain) :9 Distance fto(rt rivets water au w I r suction line Diameter If r� Comments: (condition of)olnts, vent n , evidence of f"kage,-etc.) Joint Iqo eviden ys em is ventpo thrcnicihous uop SEPTIC TANK: (locate on she plan) Depth below grade:10 Material of construction: concreter6-LmetaiFlberglass4ld PolyethyleneAQQther(ezplaln) II tank Is fnetal, list age kW is.age.conRrmed by Cor-01cate of Compliance ./- (Yes/No) Dimensions: /r tz? ���( f0; S' y Sludge dept -4dQt r Distsnc• hom top ofsludge to bottom of outlet tee or baffle" Scvm thickness: 1;U4- -� Distance from top of scum to top of outlet tee or baffle: .L " Distance from bottom of scum to boT%?ry of outlet tqp or baffle:_J� � Mow cimensions were deterrnlned: Q r� , Comments: (recommendation for pumpin condition of In and outlet tees or•baMes,.depth o}liquid level in(elation to outlet invert, strvCtvrsi.nteprity. evidence of leakage, etc.) YUm septic /Inlet & outlet tees are in place qui ep a t e out ; n L-rt- - f; ft.r one ; n(- pc 'I-Iie tank is structure 1 1 y Gn„ne9 ;4Qd chQQ gr, evidpnrp at GREASE TRAP: (louts on ills plan) Depth below grade. Material of construction:r )—Aoncrete�metal,4/V Fibs rglass Polyethylen other(explaln) pimenslons: Scvm tNcknes$:_� Discsnu from top of $cum to top of outlet tee or batfle:-42AL. Distance from bottom of�scum to botom of outlet tee or.bsMe:— Dete of last pumping: ALL Comments: (recommendation for pumping, condition of Inlet and outlet tees or boMes, depth of liquid level In relation to outlet IrsveM et►uctur&I Inc.pr" evidence of leakage, etc.) rease j2 G� n—n .rr�ve; revised 9/2/98 Pa`e7of11 IVUURIACI ICWAO[DUPr AI:YST>EU Wtf MON K.." ►AAT C iy1TEA1 WFORiAAT10N (candnuo0) /tiop.rry Adae.a 1 08 Bay Road Cotuit,Mass. Owr--w: Craig Flemming 1 /1 /0 0 T1O►fT 01t NOLDWO TAXK:jLj,(Tank rnvot be pumpod prloi to, or •t tlmo of, Inopostfon) Uoc►to on ►Ito plan) Oopth below prodo:-LIA2 MotorlaJ of con►trvctlon:i2wcr fit l22mot+1A4Flb9rgl&#s&/olyl;thY`lcn9,�L- othsr(9splaln) 1 14 Olmsn►Ions: CopsclTy: gallon► Oo►ipn flow: ' p►llons/day Atorm pH►onl Alorm IeY►I: il Alum In orklnp No&f Oslo of prevtovs pvmpinII / _ Commenu: Itondroon of INol too, oondltlon of olorm end Most owltchoo, oto.) O43TRIIVnON IOX:LI-1 Uo(ots on silo plan) Ooptn of liQvid level above ovdel Invert:A C�ownents: o�o q dense of lookepo Into of wt of ►os. otc.l — IIJieSl rlbnugiori bo1 ovldonw ollaalLaecraTv.r.No evid carr i enc e ox NWp CM&ABEA:d,01XGIe Ilocsto on silo plan) wmp►In worklnp ordor:(yes or No) Alums In working ordor (yes or Nol_zo Commonts: a end•ppurtoneu►eee, •te.l mots condloon of pvmp chombor, condition of pvm p U ►spiel)) revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA PART C SYSTEM INFORMATION (contlnuod) Pv,o9w-ry Adreit: 108 Bay Road Cotuit,Mass. Owrw: Craig Flemming Det s of lnspection: 1 1 /1 /0 0 () SOIL ABSORPTION SYSTIDA(SAS):�AyL7�� Ilocate on Nit plan, It possible: excavation not required, location may be approximated by nonantruslve mrthods) If not located, explain: Type: latching pits, number: leeching chambers, number: leeching galleries, number:_ leaching trenches, number, length:__Z�j_____ latching fislds, number, dimensions: overflow cesspool, numbtr. Alternative system: Name of Technology: r C.-`� e✓ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp toll, condition of vegetation, etc.) Loamy sand to mar9; iim Q=-nd t;e €€r;:e 6;aeEl CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to Inlet Inven: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Alw Inflow (cesspool must be pumped as part of Inspection) poo s are not present - -- Commtnu: (note condition of soil, signs of hydraulic failure, level of ponding,oondidon of.vegetatlon, etc.) PftlVY:'t)*1 flocett on site plan) Materials of construe qn: Dlnwnalons: Depth o1 solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegstatlon;etc.) riv revised 9/2/98 Pset9or11 SUI3URFAC19 IEWA01 Ct3POSAL NYfTIDA 1Ns►ECTION FOWd , FART C SySTDA WFOP.16 AT►ON 10*n*v-d) 1 08 Bay Road Cotui.t,Mass. 0 Craig Flemming o fu 01 Ada+: 1 1 /1 /0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: IncJvd, t 11 to &t I#&it two pq(rn&n*nt r9fornncs landmuki or bonchmuki 104411 NI wollr wlWn 100' ILotill whers public w&t6r wpply corns Into houaf) �v f� 0 revised 9/2/98 n�� 10 of II SU&SURFACE SEWAOE WNSAL SY3TEm WS►Ecnom roRm PART C 3Y3TDA W FORllAMN Icon*-0411 I►9q.rtyA6&*": 108 Bay Raod Cotuit,Malss. Own"(: Craig Flemming Dee ofva-p :11 /1 /00 NRCS Report moms $ou Type_ TyplcN depth to proundwrtrr VSOS Osta web►Ite Ailted Ooservation Wells chocked Orovndwater depth: Shallow�_Moderste Deep SITE EXAM Slope Svrlsce water Check Caller Shallow wells Estimeted Depth to Orovndwater St-Feet Itesse Ind7c8te all the methods vied to determine High Oroundwater Vevetion: _ Dtalned from Design Plans on record �QD(erved Slta (ADutdng Drop art obasrvstion hole, basemeot sump etc.) Oetarmine0 from local conditions Checked with local Board of health Checked FEMA Maps _ Checked pumping records Cnecked local escevstors, Installers Used VSGS Oita Oe►criDe how yov established the High Groundwater EJevatJon, (M.Yg be completed) Used; Water contours map. Gahrety & Miller Model 12/16/94 revised 9/2/98 hit lloJll Barnstable '1'UNN OF I10ARU OF IiZALTII 9U1)SU11FACF 9FWA0F 1)19I'U9AL ,SYSTEM INSPECTION FORM PART D •- CERTIFICATION .n-�.,... .-..i..-.w+rv�►www�+t�wwr.�w►+w��.�.�r�.-�w�w-rw�wlwwwwR+T� ww v...-r.- r--�. _. -TYPO OA PAINT CUAW— PROPERTY IKSPECTED STREET ADDRESS 108 Bay Road Cotuit,Mass. ASSESSORS HAP , BLOCK AND PARCEL i OWNER' s NAHE Craig Flemming PART D - CERT.LFICATIOIY NAME OF INSPECTOR Joseph P. Macomber Jr, COMPANY NAHE Joseph P . Macomber &'"'Son, Inc. COMPANY ADDRESS Box 66 Centerville _ MA. 02632-0066 Streit Tom or C ty state LIP COMPANY TELEPHONC ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 CCRTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this nddress and that 6 e information reported is true , accurate , and omplete as of the time or .. inspection The inspection was performed and any recolnmendatio►Is regarding upgrade , maintenance , and repair are consistent with P my• trainingand ex erience"in the proper function and maintenance of on- site sewage disposal systems , Check-- one :c '� System: PASSED The inspection which I have conducted ha.s not found any information which indicates that the system fails to adequately protect public heRlLh or, the environment as defined in 310 CHR 16 , 303 . Any failure criteria not evaluated Are as stated in the FAILURE CRITERIA section of this form . System FAILEUs The inspection w)lich I have con tucted has found that the system fails to protect the E)ublic health and the environment in accordance with Title 5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form, -e J Inspector Signature Date Dt ne copy of this c rt., ication must be provided to the OWNER , the BUYER . r. . a'pplloab whle ) and the DOARD OY' HEALTH, �`� � pgrade ' the system If the inspection PAILLD , fhb owner or operator shall u within one ,year or the date of the inspection , unloss allowed or required otherwise as provided in 3.10 CHR 16 , 306 , partd . doc AsBuilt Page 1 of 1 T WN OF BARNSTABLE , LOCATION SEWAGE# VILLAGE ASSESSOR'S MAP &LOT j3d,� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 10 (sue) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMP LANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply.Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any etlands exist within 300 f t f leac ' g facility) Feet Furnished b 110 �� o i l�. 0 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=007022&seq=1 11/20/201� LOCATION SEWAGE PERMIT NO.. .?7 Bats R2J- VILLAGE Al INSTALLER'S NAME & ADDRESS L c GF,r2,� L OR OWNER / R inee me our S T, n N Q 2 i o DATE PERMIT ISSUED _3�y�� � DATE COMPLIANCE I-SSUED F' H�vsE / (fiat. 37 ~\ I .f PIP- 'a � . ALl"� I3f1 -o , No......................... .. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD a OF .-HEALTH", \�• t Y ................. . I: ..... .....OF..... Appliratiun -fur i uutti= is k Chun rnrtiun rrntit Application is hereby'made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: ---------•............. Location-Address or Lot No. Owner Address................................ ......J2®-5 7-k....... !........IY . Me....../�1� flnstaller Address __---_.-S feet d Type of Building Size Lot.................... q. Dwelling—No. of Bedrooms............... ------------------- Expansion Attic ( ) Garbage Grinder VYP Other—Type of Building ____________________________ No. of persons.........-.................. Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- �`�--- --------------gallons. W Design Flow..................A$..0................gallons per person per day. Total daily flow_________ __ g WSeptic Tank/-Liquid capacity------------gallons Length................ Width.-__-..-..-.._. Diameter-------.-------- Depth---------------- x Disposal Trench—No..................... Width.......�,_. ._.. Total Length-------------------- Total leaching area_.-ll.-1....sq. ft. Seepage Pit No......./-_.__."___- DiameterA". Depth belo�j' inlet____________________ Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0 -7 6 P Percolation Test Results Performed by._—_.- .,____ _ - ._-______________________________ Date---3.: 1_-.7 �_______._.---. a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...---.--_-_--.-_------- (� Test Pit No. 2................minutes per inch Depth of Test Pit--____-_-...___---_- Depth to ground water-_.--..--_--__--_-__.... . • ............................................... ...... O Description of Soil---... �-••- ' ° {- . .. ... . + _ . -o-_, W ------------------------------------------ ------------------------------- --------------------------------- ---------- - ------ --------------------------------------- ------------- V Nature of Repairs or Alterations—.Answer when applicable.-.___-•---------------------------------------------------------------------------------------- -- ------------------------•-------=-•---------------------------------------.--.------------------•------•-•----•-------------------------------•-------------•------•-••-•-----•---•------------------- Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—T n rsigne r"th gree not to place the system in operation until a Certificate of Compliance has been issued b t e and of ealt . Si ed... •-••••---••....• ......-••--•-•--•----------••--••• ---- -- ------------------------------- �� - Date , Application Approved By--- - - -----;....... - _'/``--� --------- Application Disapproved for the following reasons___________ ______ ___________________________________________ ------•----"- Date ------------- ------------------•---------•------•-•-------•--......-------------•----...------...._..--"-------------..-•--.........-•---------••--------------------------------•----------------__-----•---------- 'r 2 41 7 7 Date Permit No. Issued. -------------------- Date 057 No.. .......... t .l rti � F�s.....f+5....'""�....... THE COMMONWEALTH OF MASSACHUSETTS r � BOARD .OF HEALTH _._....OF..... ---- ..... ...................._------------------- Appliration -for Diq > jai Workii Towitrttrtion Vanift _ Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .....-... ......-- == -----•---- Location=Address or Lot No. ......--••--•-----•--------•--------------- Owner Address W Installer","'. Address ^'r Q Type of Building `, 4` Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------`-_..__-._-t::-_____-.-.-_..'•_Expansion Attic ( ) Garbage Grinder (f) aOther--Type of Building .......................a•_..' No. of persons-..--__--.-_-____-_-__-__- Showers ( ) — Cafeteria ( ) a4Other fixtures ------------------------------------ - - ----------------------- -------------------------------------------------------------- Design Flow................... ..�rj r -_-_-__.-gallons per person per day. Total daily flow---......� __"...._----------gallons. W :< Septic Tank Liquid capacity --------- Length---------------- Width------------ .. Diameter---------------- Depth---------------- Disposal x Trench—No Width___.______.. Total Length____________________ Total leaching area'�_O_f_----sq. ft. Seepage Pit No.._____ ..._.__.._ Diameter '- �_. Depth beloy� inlet_.____________ __ Tot leaching area.--__.-..-----_--sq. ft. z Other Distribution box ( .).. Dosing tank ( ) 41 1"3'h' 7�' p a Percolation Test Re ?; 'Performed by.,�.:-�'./y,�..__ ��,;,� Date__ Test Pit No. 1_____________...n)mutes per inch Depth of Test Pit_------------------ Depth to ground water..-----.:----.__-------. G� Test Pit No. 2---------------minutes per inch Depth of Test Pit..-___-___---•..____ Depth to ground water---------.. ---------- .. ----- --- D Description of Soil------ .._ or„ ® Ei ate«+; l: +. +�• - - ----- -- ----- - W U Nature of Repairs or Alterations—Answer-,when applicable.-.- ............. -. .----• ------•-----•------------•------•--------------------------------------- Agreement The undersigned agrees to install the aforedescribed Individual 'Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code_—` T in rsigned urtVhgree not to place the system in operation until a Certificate of Compliance has been issued b t e 'and of ealt xSi ned-- - -- - ------ --•----------------- ate Application Approved By.-- �'-• r " 7D---------------- ;y Date Application Disapproved for the following reasons:.......... •----- •---••------•-------------- =-------- ----------------------------------------------- ---•...................•-------•---•-----••-•---•------------•-..........--•-•--••-•---•-••--------... ---------------------------- --------------------------------- ---------------------------- Date PermitNo......................................................... Issued.------....----- ------- -----------------•---=......--- ?" Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL ' Trrtifirate of (Sautpliattre. THI IS TO P I T t the Individual Sewage'Disposal System`constructed ) or Repaired ( ) by ��' V-- . - ----- ................... ....... ----------................................................................................. Installer at..r / �.._. � ------- ---------------------------------------------------------- has been installed-in accordance with the provisions of :AefiQXI of The State Sanitary Code as described in the ?7' „C- 7► application for Disposal Works Construction Permit No. .................... dated....__��-__. �J'_�_.'__-.7-.----_.__........ THE ISSUANCE OF THIS '6tRT1F11CATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM VOLL FUNCTION SATISFACTORY. DATE....................................... r= -Inspector-------------------------------------------- `' THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALTH ,"' 7T 1•... ....OF...........". ......t.................... � � .......... . No..... ........ FEE.......... �i����tt Permissio is ereby granted_._____ ,( .._ -_ �F� - to Construct �or Repair ( ) an I ndlv'j ualAewagge Disposal System at No....s..� 7jp�. .._. ...,..-•_-._____----.------__-•-..-___--•••--.-B------------------------•---------••----•-•••_---------- Street as shown on the application for Disposal Works Construction P t Dated___ `- .................. DATE................................................................................. "Board of He FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .r�r` \ � i TOWN OF BARNSTABLE '- UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION MAP NO. t/ i PARCEL NO. r ADDRESS OF TANK: l ?_, r1 w z4c)- VILLAGE: C) f l N u m b r Y t w w! MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : OWNER NAME: A/i 3 L./ �' .__._ �';',�' 4srr d PHONE: C/ INSTALLATION DATE: f� BY: '-,�, / 1 - 1 a INSTALLER ADDRESS: 'CERT.NO. *TANK LOCATION: �/� �- � Fee,LA , (acmow z'ac TAtNMC l_OQAT 2 ON W 2 TH RC=PQCT TO mlJ 2 LD 2 NO) C A P A C I TY 4'rd l TYPE OF TANK cC h,•- AGE � .� YRS. FUEL/CHEMICAL TESTING CERTIFICATION [ ] PASS -,.[ ] FAIL DATE "A LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND) ZONE OF CONTRIBUTION [ ] YES [ ] NO DATE TO BE REMOVED t t. 0 r FIRE DEPT. PERMIT ISSUED [ ] YES C ] NO DATE CONSERVATION [ ] CHECK IF N/A DATE BOARD OF HEALTH TAG NO. C ] DATE f 1 r 111 - � ?k PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE HACK OF THIS CARD P P CIO INII 1 � ® M m � o � rn r :� 1 M147N -7 f 4y G-ENFRRL N OT ES \ \n,S+xcJ ! 1 k..-,"r co ( See liNftr-.QV-1 T7)06r1Y< or`. Pxo-r P1Mr,11 c) gp ewrib ca FLOW -LINE 2.1 c Ir- ,rli -*S cLrr*m T-YZI.1.'A -MMI-ET ouni-iT, _J 3) (Da r c D -Y RT -VION SEI=Tlr- 7,nlq K box LEFC4. PIrr /; �� :/ - ,- -'To bft 4�ornd4 \VN 19M ov-v\, c�s -ro be TA =o",Cr*v-rr-) PROFILE OF S"YSTF- Nll\ NO 5 C)9t -vam c�t-o4qk� or j.%, rn CnT,\4tr-kz,k� L -T ur =Anc, Sopmr- Q-Km4 N:)"6�\ �- `�` �" gm. Rp,� , wr . S-t l=e Zl©oo 1-6. Vsvik- SN' Z-rw-�, L 2()\O00 -Y\-W boTtt�m o� �xca va�o�s -4e.r Ss c o S 1aa 'Tc) SEFrrkC -TF4 WK. A pvjt'c�wr P=ln 7,9- IP�� -0 0 )t/-- H r->IT <Nr-�A 100 -All q0 PL RN \Vj W 0 F- S\�ST E M NO SCRL-E 3 13> 6,113 / 0 7ES HOLE PERCOLR-TIC) N -TF-S-T RESULTS Y9 6 6 V llo9 -7-10 ot/ F-T%,nivo F- 4 VA" CD 0 a 00 0 LP C T PL A N 6 9�p N S-r HE I EY 2 a pa�N C -ilk �rl 0 ,-J E _AT J4 VT* D N S REGISTERM V)ROFEC�'��>MON"L- F-N SCHEDULE OF ELEV R 70 p ai �.-r %VT TgaK X'�Az'r M"v4sy,r ri Tx?.p wr 0-42 4 ' -TXPICRI R LE RCHIN PVT rn\4ftr- wrwffr'. J. off- bo-T-r r-r. L&-exr-"irj r --5 J.C7 PEC%T G E FT F- %C)Ri<D OF VA EF V)L-TH