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0049 BOB-WHITE RUN - Health
'49 Bob White Run Cotuit A= 140-100 7//q TOWN OF BARNSTABL.E LOCATION' / 60 6 - 1jhW : e W. .•` SEWAGE # VILLAGE _ �U�� ASSESSOR'S MAP&LOT _ 1 INSTA:1 LEIt'S NAME&PHONE NO. SEP11C 'TA.NK CA.PACI TX 15 6 o "' "a L.iAClavc pACL�IT}r: (type) �f�NO.OF'I�EOROOMS 3 BUIL DER OR OWNER., W-- ' PERMIT®ATE?:.�... .� _b - ._ct�lyTi'I.IANNCE OA'JCE__�__: Separation Distance Bctweq the: Maximum AdjusW,Groundwater Table to the Bodoni of Leaching Facility Fee Private Water Supply Well and Leaching Facility (If any wells exist i on site or within 200 feet of leaching facility) -- Fee! Edge of Wetland and Leaching Facility(Lf any exist within 300 feco lleachin .f sec Furitlshed by �► ,C o � p ' � v 1 A � C TOWN OF ARLC7 LOCATION v C SEWAGE # VILLAGE ASSESSOR'S MAP & LOTO, OJ -iER!&NAME&-Ia1 GNE—NO. Y1741"Y 4�L)aaa L 6 � SEA` IC CAPACITY O LEACHING FACILITY: (type) (size) NO. OF BEDROOMS // BUE'DER.0 e- �� PERMITDATE: `eO E DATE: '12V,-)a c2 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 9s �� ' � O G �` O -i . � . Q),-- S OWN OF BARNS���Z E�-- LOCATION k 4 -6-1 861 WO re Ru V SEWAGE # -)6W VILLAGE Co 1 v ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. v mr c,f C40 C2 SEPTIC TANK CAPACITY LEACHING FACILITY: (type)-Zy ri/Tr�T r f tens a (size) NO.OF BEDROOMS 3 BUILDER OR:OWNER oz PERMUDATE: Uo COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 6 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 f leaching faciii Feet Furnished by �,� c� 11� )- o 31 9� ® ,� C `R '"•ue _4 —rj .CP Family Room Paved Paved 35�x9' Patio Patio 9'x8' 11'x1o' 12'x7' Bonus Storage Room 27'x12' 12x10' NO ,R E-2 S l� All measurements are approximate and not guaranteed. This illustration is provided for marketing and convenience only. All information should be verified independently. © PlanOmatic Deck 27'x6' If 00 1001 L �a Deck 11'xi1' � , , Kitchen II""""" 12 x10 Dining 22'x11' { 7 00 100 Room 6ne 12'x1o' Master '14'x12' Living Bedroom Room : 16'x12' Wx12' t All measurements are approximate and not guaranteed. This illustration is provided for marketing and convenience only. All information should be verified independently. © PlanOmatic 0 Bedroom Bedroom 16'X20' 13'x20' F All measurements are approximate and not guaranteed. This illustration is provided for marketing and convenience only. All information should be verified independently. 0 PlanOmatic I Apr 19, 2017 22:16 Jim The Inspector Man 5085349919 page 18 ®a Commonwealth of Massachusetts X0 Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 49 Bob White Run Property Address �. John Piroski r Owner Owner's Name •� information is i required for every Cotuit I/ MA 02635 4-17-17 page. Cityrrown 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. Important:out forms n A. General Information filling out forms on the computer, J�# a o1 S-0 use only the tab 1 Inspector: .� key to move your `��,• ,' � cursor-do not mA M ES James D.Sears Al g: .N use the return =z• ;ms key. Name of Inspector ^0. .Sco c Ca wide Enter rises Q Company Name , I ,. i����q S�f 153 Commercial Street Company Address Mashpee MA 02649 City/town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15,000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority. I 4-17.17 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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.doc•rev.6116 Tide 5 official Inspection Form subsurface sewage oisposal System•Page 1 of V Apr 19. 2017 22:17 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name information is required far every Cotuit MA 02635' 4-17-17 page. CdylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,.C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. H-20 Tank D Box and five chamber's B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or;'not determined"(Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5 ns.doc•rev.6/16 Title 5 Official Irupection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Apr 19, 2017 22:17 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob White Run Property Address John Pireski Owner Owner's Name information is required for every Cotuit MA 02535 4-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box, System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1►(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland Ora salt marsh t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 I Apr 19. 2017 22:18 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name information Is required for every Cotuit MA 02635 4-17-17 page. CitylTown 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 systemiis functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent;and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or.system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than Y day flow FAl' /NG l5ins.doo•rev.61)6 Tills 5 Official Inspection FDrm:Subsurface Sewage Disposal System-Pape 4 of 17 i Apr 19, 2017 22:18 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments is 49 Bob White Run Property Address John Piroski Owner Owner's Name information is required for every Cotuit MA 02635 4-17-17 page. CltyfTown State Zip Code Date of Inspection B. Certification (cont) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation, ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system iis. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. _ E) "Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6r16 rUe 5 Official inspedion Form:Subsurface Sewage Disposal System-Page 5 of 17 Apr 19, 2017 22:19 Jim The Inspector Man 5085349919 page 23 �L\, Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 49 Bob White Run Property Address John Piroski Owner Owner's Name information is Cotuit required for every MA 02635 4-17-17 page. cltylrown 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.doc-rev.6115 Title 5 Official Inspection Pon:Subsurface Sewage Dispeeal System•Page 6 0117 Apr 19 2017 22:19 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name information is required for every Cotuit MA 02635 4-17-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. H-20 Tank D Box and five chambers Number of current residents. NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No. Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)). 2015-84,000Gals Detail: 2016-79,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commerciallindustriall Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/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: lsins.doc•rev.6/16 Title 5 Official Inspection Forltl:Subsurface Sewage Disposal System-Page 7 of 17 Apr 19L 2017 2220 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts lam Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name information is Cotuit required for eve MA 02635 4-17-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: pate Other(describe below): General Information Pumping Records: Source of information: NA 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) ❑ In technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doe-my.8116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17 Apr 19 2017 2220 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not fior Voluntary Assessments 49 Bob White Run Property Address John Piroski UV Owner Owner's Name information is required for every CiotUlt MA 02635 4-17-17 page. Citylfown State Zip Code Date of Insp ection D. System Information (coat.) Approximate age of all components, date installed (if known)and source of information: 2001 Permit # 2000-575. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 42" 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.): Pi ein is 4" PVC SCH -40. Septic Tank(locate on site plan): Depth below grade: 32"rBet _ Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: 1500 Gal. Precast H-20 Sludge depth: 2" t5ins.doc-rev.elle Title 5 Official InspectlonForm:Subsurface Sewage Disposal System-Page 9 of 17 Apr 19 2017 2220 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name information is COtUIt required for every MA 02635 4-17-17 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 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt- Plan-Tape _ Sludge Judge 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 at working level. In and outlet tee's. Tank and outlet cover at 32"below grade wAnlet cover at 8". No sin of leaks a or over loading. Note: H-20 tank in shell drive way, 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.Coc•rev.6l16 7ltle 5 Official Inspection Form:Subsurface Sewage Disposal Syetem•Page 10 of 17 I Apr 19 2017 2221 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name information is required for every Cotuit MA 02635 4-17-17 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level,' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5lns.doc rsv.6/16 Title 50f1idal Inspection Form Subsurface Sews Dis posal sp osef System Pape 11 0l 17 Apr 19 2017 2222 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form :N 9 P Ys of for Voluntary Assessments 49 Bob White Run V - Property Address John Piroski Owner Owner's Name information is required for every Cotuit MA 02635 4-17-17 page. CityrTown 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.): D Box is 16"x16"-4'below grade w/one line out Box is old but solid w/some solid carry over, Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why. 15ins.doc.rev.W16 Tltle 5 Official Inspeclion Form:Subsurface Sewage Disposal System•page 12 of 17 I Apr 19 2017 2222 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name information is required for every Cotuit MA 02635 4-17-17 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number ® leaching chambers number; 5 ❑ 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.): Leaching is five infiltrator's w/3' stone. Ck D Box and camera out to chambers. No sign of over loading. 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 ISina,doc-rev.6116 Title 5 Dnicial Inspection Form:Subsurface Sewage Dis posal SpOael System•Pape 13 0l 17 Apr 19 2017 2222 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bob White Run . Property Address John Piroski Owner Owner's Name information is required for every Cotuit MA 02635 4-17-17 page. Cityrrown 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.) tfiirmdoc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systen-Page 14 of 17 Apr 19 2017 2222 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts AM(F. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name Information is required for every Cotuit MA 02635 4-17-17 page. Clty/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 referencelland marks 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 et rRs�� r� 0r -�---� 514 �,�� t5ins.doc•rev&16 TiUe 5 Offlcial Inspection Form:Subswface Sewage Disposal System•Page 15 of 17 Apr 19 2017 2223 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name information is required for every Cotuit MA 02635 4-17-17 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to high ground water: 101+ feel 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: 12-22-99 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: T.H_ on Design plan 12-22-99 no G.W. at 12'+. Bottom of chamber's at 5' below grade. Bottom of chamber's at 7' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lns.00c rev.w6 Title 5 Oladal Inspection Forth:S W surface Sewage Disposal System.Page 16 of 17 Apr 19 2017 2223 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob White Run Property Address John Piroski Owner Owner's Name information is required for every Cotuit MA 02635 4-17-17 page. City/Tom 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 t5ir3.doc•rev.e/16 Title 5 Official InspectOn Form:Subsurface Sewage Disposal SyC1eM•Page 17 of 17 9 n � �1 .[+Q��✓ � �? �' �' 1�-' FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, SAQ'O 1 ASS--G , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct),�Repair( ) Upgrade( ) Abandon( -)<Complete System ❑Individual Components Location *15S 009 w t+ITE (zoo Owner's Name M I CKAG:7LSOO W I LU 5 Map/Parcel# Mlv53 1 Address 4--73 Pow nr(Za�,-7- (f -VI L c- Lot# 2 Telephone# �Jd • / 20 2- Installer's Name TI CHA%r V Designer's Name A 45 - Address 0 dRr-- A A-� MA-. Address /6 )O��f W 14/6/k) �� �,fy&A-/ Telephone# / Telephone# 5 o. g Z 0 Type of Building �Eu��7 Lot Size 3 1 t c�� sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) �J 7J� gpd Calculated design flow 33 Design flow provided -S&0 gpd Plan: Date ADy• 31, L•000 Number of sheets 2- Revision Date --- Title ''lVE A 5e^WA4.E pISPo5,4L Qt&t? [�61 2, S9 L3oF3 W++i ;5 t2UP Description of Soil(s) M60. r,7 Soil Evaluator Form No. Name of Soil Evaluator LANwe ' � ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 1 The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further afire to not to place system in operation until a Certificate 00of Compliance biLs been issued by the Board of Health. Signed Date lf�^ �� — 0 FEE a r i - _ �• Board of Health, i+./XFF..� APPLICATION F®R,.DISP®SAL SYSTEM CONSTRUCTION PERMIT ?�,A lication for a Permit to Construct /Re air U rade Abandon Com lete S tem ❑Individual Components PP (7r P ( ) Pg ( ) ( ) p ys p r P/ . Location ' +V' 159 WS W 14 1 TE I2,e,,,)jJ ? Owner's Name M'ap/Parcel# 9AI-5•3 Address 4-''75 P itCe t Lot# �. Telephone# ZCQ 2. Installer's Name Tj N r,. F KC V l 0 Designer's Name F Address C Address /� oR D LE N1 - Telephone# „S�Q$i's 3C� ® Q Telephone# Type of Building: Lot Size 311 500 sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other Type of Building No.of persons Showers ( ),Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Calculated design flow 0 Design flow provided; `�J&'0 gpd Plan: Date AV y • r• r'oC Number of sheets 2 Revision Date Title' �r1� � 51E cWAG� DISPoSA(_ PLA O LUT 2 , � 5g 13U� W+4 1 � 12�jt-� Description of Soil(s) ✓2 Soil Evaluator Form No. _ Name of Soil Evaluator LA-WlfaS- C.WLC-)bate of Evaluation Z 2 Z g} • ! j pp DESCRIPTION OF REPAIRS OR ALTERATIONS 37• 3 x �'DJ E 1w1 ' J r/t+'t< 1 ttt7Ur S_ a 3 Q f , The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of•TITLE 5 and further.agre t to not to place the tem in operation until a Certificate of Compliance h .beemissued by the Board of Health. Signed �' ' 1 Date.• ^ re ff'r�4 No. rlA'!�' COMMONWEALTH OF MASSAC14USETTS Board of Health, MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) 4'Complete System The undersie ned hereby certify that the Sewage Disposal System; Constructed ( i ;Repaired ( ),Upgraded ( ),Abandoned ( ) by: -� at =/ t,• has been installed in accorda ce with,.the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No "& .4 `� ated"" s 470�a0fMpproved Design Flow (gpd) Installer Designer: Inspector: � '1�. `� Date: ,f The issuance of this permit shall not be construed as a guarantee that the system will function as designed. t FEE f COMMO WEALTH OF MASSAl_HUSETTS Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( A, Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at � � �i��""F[" �r ,.�" ` �jg as described in the application for Disposal System Construction Permit No!VOJOW Zi dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date _ _:,Hard of Healt _ Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information for every n is required Cotuit MA 02635 2-18-11 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 Service Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-5087495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-19-11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of10,000 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 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: ® 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. 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 exfiltrafion or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 page. City/Town 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 y ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is-equired for every Cotuit MA 02635 2-18-11 cage. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/ 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 M— y 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ED Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems:.To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply. Elthe system is located:in a nitrogen sensitive area (Interim Wellhead Protection El 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 CIVIR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 4 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name Information is required for every Cotuit MA 02635 2-18-11 cage. 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? ® 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 l Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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: Sump pump? ❑ Yes ® No Last date of occupancy: 2-18-11 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 11-2010 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other (describe): t5ins•11110 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 38 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. Septic Tank(locate on site plan): Depth below grade: 30"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal H-20 5" Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 9 of 17 S. Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 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 27" ' • Scum thickness 0 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M - 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 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 from field. I 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 Inspection Cit !Town State Zip Code Date of Ins page. Y P D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: � leaching trenches number, length: 1-8.83'x37.25' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach trench in good condition with no sign of back-up into d-box or surrounding stone. 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 2 of 17 v ' Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M "< 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 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-11/10 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 — 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 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 c 0 � A-Q t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 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: Original design plans show no groundwater at 12'. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bob-White Run Property Address Carlos Marques Owner Owner's Name information is required for every Cotuit MA 02635 2-18-11 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s W TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: w1„ Q---� Owner's Name: Owner's Address: A, OS3 Date of Inspection: �j Name of Inspector:�please print) �C)N ( K-aej 1 Company Name: wv� r�C 2v1 ► �� �HS�QGtdh Mailing Address: ?O 13ng �lal 6 y -v Telephone Number: S�Z� _;t9.S 76 D9 1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inf©rmation-reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on' "my F training and experience in the proper function and maintenance of on site sewage disposal systems!I am a DEP ate approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: c r ? 2L Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority {` /Fails/ c.._. Inspector's Signature: alp Date: l S 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address stow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Qoff- Owner: o b,!Jtm Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with, approval of Board of Health): broken pipe(s)are replaced obstruction is.zemoved distribution box is leveled or replaced. ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A `'[�I CERTIFICATION(continued) Property Address: Kq 1Z b$0 W"n 4- 6 L* Owner: R:�%'-P—Tro Date of Inspection: (t�,�d7 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to Bete ne 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 C 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safet 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 o a salt marsh 2. System will fail unless the Board of Health(and Public W er Supplier,if any)determines that the system is functioning in a manner that protects the public h lth,safety and environment: _ The system has a septic tank and soil absorption s tem(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water s ply. The system has aseptic tank and SAS and t SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method ed to determine distance "This system passes if the well w ter analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic co ounds indicates that the well is free from pollution from that facility and the presence of ammonia nitro n and.nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL..INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DAPOSAL:SYSTEM INSPECTION FORM PARY A. CERTIFICATION(continued) Property Address: q " Iw"� Owner: Date of Inspection: I L(l a c J 0 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 o 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'/a day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ 41 Any portion of a cesspool or privy is within a Zone 1 of a public well. a Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory;for coliform bacteria and volatile organic.componmds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal,to_or less than 5 ppm,provided that no other.failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve-a facility wi a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the followina- (The following criteria apply to large systems in.addition to a criteria above) yes no _ the system is within 400 feet of a surface ing water supply the system is within 200 feet of a trib to a surface drinking water supply _ the system is located in a nitrogen ensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply ell 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 syst m 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B (CHECKLIST Property Address: Db t, l" Owner: LoOR1r'o Date of Inspection: uT_ko- Check if the following have been done.You must indicate"yes"or``no"as to each of the following: Yes No jL _ 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 ot-he 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 m mtenance of subsurface age ew disposal sal systems stems? s d The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION � • Property Address: t(1Q �A Owner: i b eA ro Date of Inspection: (( $A I n�? FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): u*7 c3D Number of current residents: Q Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): A/a[if yes separate inspection required] Laundry system inspected(ye e or no): OVO Seasonal use:(yes or no): AN _ Water meter readings,if av ilable(last 2 years usage(gpd)): Sump pump(yes or no): � Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15. ): gpd Basis of design flow(seat s/perso gft,etc.): . Grease trap present(yes or n ._ Industrial waste holding present(yes or no):_ Non-sanitary waste di arged to the Title 5 system(yes or no):_ Water meter readin ,if available: Last date of occu cy/use: OTHER(d cribe): GENERAL INFORMATION Pumping Records /( Source of information; Aj 0 %.j 5MM 6%n, S '% A&a 1 A A JWAl Was system pumped as part of the eInspe t�yes or no): " If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM �( Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank ,Attach a copy of the DEP approval Other(describe): P Approximate age of all components,date installed(if known)and source of information: 0 S Were sewage odors detected when arriving at the site(yes or no):_D 6 f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM"INFORMATION(continued) Property Address: O b W Aake—Q0A C O tit' Owner: Q",b C.V-o Date of Inspection: 1,L V BUILDING SEWER(locate on site plan) K Depth below grade: 3 6� Materials of construction:_cast iron R40 PVC 'other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: 4 (locate on site plan) Depth below grade: cl 7 " Material of construction: gconcrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): —(attach a copy of certificate) Dimensions: t SOU S Q, Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: a" Distance from top of scum to top of outlet tee or baffle: " N 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. : L e (/ RAA a(C OV 'C i 1ti Qt&ce G Kl GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal i erglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top outlet tee or baffle: Distance from bottom of scu o bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping commendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet inv ,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i. PART C SYSTEM INFORMATION(continued) Property Address: 7 db l,(�ki'kt CV A, Owner: R t ibei ro Date of Inspection: t II I Lo"7 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_��olyethylene other(explain): Dimensions: Capacity: -gallo Design Flow: g ns/day Alarm present(yes or no): Alarm level: Al working order(yes or no): Date of last pumping: Comments(condition alarm and float switches,etc.): DISTRIBUTION BOX: 4'/ '(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: C!/M 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/� I • box Lsh (4V4j &,.j `�o!;L._u/ V44 i/bo 8 i�(n PUMP CHAMBER: (locate on plan) Pumps in working order(yes o o):• Alarms in working order(y or no): Comments(note conditio of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 J,, L nY-C�1 Owner: ro Date of Inspection: tl 1 11.22 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: 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.): _ L VC < 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 ground w er inflow(yes or no): Comments(note c dition 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 con di 'on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 f Page 10 of l l OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: y 9n;g'10b 2,. Owner: ;.r Date of Inspection: Ll _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. V V y I . aq Page I I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM (INFORMATION (continued) Property Address: W�ke Owner: Q; Date of Inspection: 11 SITE EJXAM Slope G Surface water Check cellar L Shallow wells 1N0 Estimated depth to ground water ;�5'feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: round water elevation: hi h You must describe how you established the g g u 5 GS -tv�aQ s �kc,�,.► a.k ele uct,'�lo� o �' o u2t, .a.����f . 11 Town of Barnstable P#�4? Department of Health,Safety,and Environmental Services W> Public Health Division Date 367 Main Street,Hyannis MA 02601 BARNSTABM MAMEL Date Scheduled R A> Time 1 Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed Byt1,'), LO�C TION�& GENERAL INFORMATION Location Address � � )/// C I ]�� Owner's Name 0WCI 7 - 11 Address Assessor's Map/Parcel: �CJc?(fj ��� Engineer's Name V o I . NEW CONSTRUCTION REPAIR Telephone# job.- 540 —'4-4 33 Land Use ' Slopes(%) —15 Surface Stones E p �w Distances from: Open Water Body ft Possible Wet Aiea Cp' ft' Drinking Water Well ft 60bt o or" l Drainage Way ft Property Line `�1155� ft Other ft.' � I SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) L 20' 4°I (br 2ef-53 JOHN NDEnS CAU!_EY �""•:•IA No. 35101 IST Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: a_ Weeping from Pit Face Estimated Seasonal High Groundwater ETNA O � � VATEt m�$ I".'.; .........................................................:..:........................................................................................... .....................:: :................................. . . . .... ....:.................................................... Method Used: v_ Depth Observed standing in obs.hole: Vr in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well#_ .Reading Date: Index Well level. _ Adj.factor_ Adj.Groundwater Level PEttCOLA 'tON:TEST Rate l�22. Ilme x?�C Observation ! LASS Hole# Z �G"-- ' i Time at 9" �PAO Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak �J Rate Min./inch ,N ►� Site Suitability Assessment: Site Passed 1 Site Failed: Additional Testing Needed(Y/N) j Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant DEEP OBSERVATION HILE LOG Holy Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel A Gt'wl 6b- 3O g L4, SO-120 M.S w 16 ;DEEP OBSERVATI0111 HOLE LOO Hale# .. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel 40-- 12 CIA rrk- 61a e (Qo -�� C M•�a� 2, � DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizo* Soil Texture Soil 11 Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consi tenc %Gravel w I,� y ... .: .. DEEP OBSERVATION HOLE L(l�G Hole## Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,° Gravel Flood Insurance Rate Man: / Above"00 year flood boundary ida_ .. 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 certifythat on . 9 date I have passed the soil evaluator examination approved b the (date) P PP Y Department of EnvIronmental Protection and that the above analysis was performed by me consistent with the required training,ex se'and experience described in 310 CMR 15.017. Signature Date b1-13-2.0-bV TOWN OF BARNSTABLE LOCATION iqq �63 Who y't /l�l SEWAGE # VILLAGE Co h�_ � ASSESSOR'S MAP&LOT � a INSTALLER'S NAME&PHONE NO. ZT;Ym t c, G AQ e-< —6 6 ig SEPTIC TANK CAPACITY e ed //ii LEACHING FACII.TTY: (type) r'r� r ��'�'�C (size) 8 ,*tq3 X �ZZX NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: o® COMPLIANCE DATE: Iwo I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /6 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 fe=fleaching facili ��� Feet Furnished b �t.� t rep;r �;A AE�-O-J 7 t � 0 i 0 31 �� .wssr+...n..._. .k'.a4.A4'PAPq"$T.#4°e4mLyF� - =.fAMMn7OfE. a»swa.rwwa• saw.quaaawrp.wPYa+paa4,t5uiereaH•n.sKa uFnR_" - - .. .. __, .. u�ASA.'TF'FS -. - - `%$ FIRST FLOOR SEPTIC SYSTEMi PROFILE SOILS LOG ELEVATION 72.5 FIN. GRADE FIN. GRADE OVER FIN. GRADE OVER FIN. GRADE OVER PERCOLATION TEST TOP of AT HOUSE SEPTIC TANK DIST, BOX SOIL ABSORPTION SYSTEM FOUNDATION 705 70.25 67. . 65.0 TEST HOLE I TEST HOLE 2 ELEVATION 71.35 +.,* 2'1 '! C?� OE 0" ELEV. 69.0 0" 68.5 �,AF,, ;, P s,,A.A ��• RISES $� 1 'TY/ �"/ ./ � .� I'F` i/ G >/ l .. \ i. ,►'/. ./. .,.... ». >. ,>. � �' .. i +•971t.'a' i'iag„�: .r'�,, i ',i ;i�"t'+.iL .^' �$- ",•.._. rj ."tw.. �.,. , v"�qh+' LE 5 INVERT at 6" OF FIN GRADE 16" A LOAM 12" LOAM FOUNDATION ri'";'' .: �. :i•�r. , :+.r• ELEVATION 66.30 --�, 2" MAIN,DOUBLE WASHED IY®" - 1/2" STONE J , 11 1 qq� �.. . ,, b M• • •� T L LOAM LOAM 66.00 > t 63.00 � 6263 .. � _: •,, W 65.75 61.50 Ir . ��. . ..r; •I: IOYR 4/4 t:.t�: ;�� 13� 3l4- - wt/2" : '::i�� I� 30" B lOYR 4/4 e `' ;� I ',�f i• k►, DOL�LE WASHED STONE GAS BAFFLE ON OUTLET TEE 36' 8 p �•a.,:..a :...,..._ ....�..._ .�..�...• ',:°.its .� D I T. B 0 X 3'-0" SI2g' 3'-0- MED.COARSE t••+ 3 I V V GALLON J to 37 25' TOT EF•F.LENGTH SAND Y. o H--I� LOADING T �.8 �. EFF. TH '.' SEPTIC TAN + 60" CI IOYR 5/8 ;. 16 BASEMENT FLOOR :' �'" 10 L.®A®ING TO BE SET ON A x R � ELEVATION �•;:�: `.:.: .. ... .,,...,...,•,,. .,.-.. .,. ,. ,. .; 6" CRUSHED STONE . .. • . ;..g. �. �.,,..� 61.35 6" CRUSHED STONE BASE BASE �! . t ACME DB-3 OR vi_ �✓:+"r�"+ nv '; s "'nr.,`► 'r;►<• • I IO,-6N APPROVED EQUAL ) carp MEDIUM .. •.. •.. �. MEDIUM SEPTIC TANK SET LEVEL AND TRUE TO GRADE SAND saNO ON 6" CRUSHED STONE BASE ON ( Profile not to scale ) 'g"' '� 2.5Y 6/4 2.5Y 6/4 MECHANICALLY COMPACTED NATURAL MATERIAL �/ ` 120" C 120" C2 BOB WHITE RUN OBSERVED GROUND WATER: Nye. INFILTRATOR DETAIL ADJUSTED GROUND WATER: ' 20 PRIVATE 40' WIDE ) NOT TO SCALE PERCOLATION RATE: �< 5 MIN./INCH SOIL CLASS: I EFFLUENT LOADING RATE: 074 GPD/SF Edge of Pavement SOIL EVALUATOR: J.E..LANDERS-CAULEY -__~-� --- �2• _ - CERTIFICATION NUMBER: 72 �'� 4 WITNESS: DONNA M_. I 73.2 70 72.9 72•7 T455 00 ----,z BOARD OF HEALTH, TOWN OF _BARNSTABLE DESIGN DATA DATE OF TEST: DEC. 22, 1999 �0� 67.4 `66 io 6Fr � 694 1500 Gallon ss Cl) 1 t 25' _Q �emic � NUMBER OF BEDROOMS 3 s� 6a2 <, G.P.D./ OTD LBDAII Y F OW 3 0 . .D. GENERAL NOTES 1 M , "' #� S.A S `5 w 64,, GARBAGE DISPOSAL NO G.P.D. N 3 n ROOF' � t>2 LEACHING REQUIRED 330 G.P.D. I. ELEVATIONS BASED UPON NGVD DATUM. z v i �� 65.6 70.5 N1 roe °` DRAIN f/ co LEACHING PROVIDED 380 G.P.D.. 2, ELEVATIONS AND LOCATIONS SHOWN ON THIS PLAN __�� _ �/ SEPTIC TANK REQUIRED 1500 GALLONS ARE NOT TO CHANGE WITHOUT WRITTEN APPROVAL 10 r `l' 12 a6 12 -- I 5e SEPTIC TANK PROVIDED 1500 GALLONS OF THE ENGINEER AND THE TOWN HEALTH AGENT. 54 PROPOSED �,:,. �!.3 !% SIDEWALL AREA 1154.3 S.F. 3. ALL SYSTEM COMPONENTS ARE TO BE INSTALLED IN 3 BEDROOM t e-- 56 ' .- 6 E�L13 -''�� ' 0� / BOTTOM AREA = 3_290 S.F, ACCORDANCE WITH S.E.C. TITLE V AND LOCAL HEALTH 66 � .•f � , A19_N o o Wood -<--�� / �5 TOTAL PROVIDED- 513.3 S.F. x 0.74 �• 379.9 G.P.D. RULES AND REGULATIONS. A r 41:11 36. s /� gH379.9 G.P.D./TRENCH x I TRENCHES _ 379,9 G.P.D. 4. ALL PIPES ARE TO BE CAST IRON OR P.V.C. SCH, 40. 6 tZ,`'*► 610 9 s �,. I 15' Drainage 5. THE BOARD OF HEALTH AND/OR ENGINEER TO BE Easeme 5n NOTIFIED WHEN SYSTEM IS COMPLETELY INSTALLED NOTE: EXCAVATE TO EL. OR LOWER AS SOIL so,s �,, ?--- �tMtT-01 WoR �-- �� AND READY FOR INSPECTION. 60 �-�-�-- .- ---- , � CONDITIONS REQUIRE TO REMOVE ALL TOPSOIL, SUBSOIL, LOT 1 �--�- 5`l �-.--� f - -- '� �' -�8 CLAY OR OTHER UNSUITABLE MATERIAL BENEATH THE 6. NORTH ARROW IS NOT TO BE USED FOR SOLAR 5® 573 4°3 ' , ' �- --� INLET INVERT- OF THE SOIL ABSORPTION SYSTEM FOR ORIENTATION. --�� A DISTANCE OF 5' MIN„ AND BACKFILL WITH CLEAN 5 44 SAND, PER 310CMR 15.255:3. 6.7 i 50 �' �/( Bvw#6 �2 4& .3 46 /I #7 � 46.9 44 �--''� ���---•�` �52.6 o /sue 42 Bvw#8 Cl) N{ �d REV BY DATE DESCRIPTION �Aht c!' 41 (Z 40 i o GciOSs�aN ", o BVW#9 \ " No. 12705 f, o �e 7- r - �FCtvIE 4:) 4 SITE B SEWAGE DISPOSAL PLAN / Z - - F LOCUS LOT 21 # 59 BOB WHITE RUN 4,.e _ .. �40.2 p`,N ai a; ° 28 BARNSTABLE MA. 42 _ _ Bvw#10 '�� rs� ROE' ! 47.4 / Bvw#1 1 /! G� 3 GcsrAn� APPLICANT: WILLIS MICHAELSON xo. �2ns f N� ADDRESS: 473 PINE STREET CENTERVILLE, MA. 02632 I L� ' ' � - ENGINEER: NORMAN GROSSMAN, R.P.E. � - Locus MAP --- SCALE: I _ 2000 10 MARSH VIEW ROAD ZONING DIST, FLOOD ZONE • • ELEVATION I MAP NO. EAST FAL,MOUTH, MA. • RF c __- 250001002ID . 5oe•b4e-Is2o PLAN REFERENCE: MAP SEC F BLK LOT HSE SCALE DATE DWN. BY / CK'D BYJ PLAN NO, BARNST. CNTY. REG. PLAN BK PG. SITE PLAN---SCALE 1" = 20' 24 53 2 ;':59 AS NOTED AUG. 31, 2000 JTH / NG H- 657_2