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HomeMy WebLinkAbout0006 BOB-WHITE RUN - Health �6EBob"White,Run Cotuit _ A= 010 027 i� I� I i o TOWN OF BARNSTABLE L".CATION �� ��r� 40 SEWAGE .VILLAGE ASSESSOR'S MAP&PARCEL .INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 1 aad �F L C'sr�3 ar LEACHING FACILITY:(type) ZJ C Z Cr� �..J ��� (size) le rX 'Te NO.OF BEDROOMS .OWNER PERMIT DATE: 3, S'r1 d 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, 0 ILK v qN' J No. A� Fee A�Ft/,� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Ztppr%cation for �Bi :"Upgrade o� Y &pgtem Cootrurtton Permit Application for a Permit to Construct O Repair( O Abandon O ❑.Complete System I Individual Components Location Address or Lot No.6 54 4/4 Te U,,) Owner's Name,Address,and Tel.No. rdf0--tj qjC "` Assessor's Map/Parcella b:7 g G" Installer's Name,Address,and Tel.NoJ°�%r /��T/ tJ Designer's Name,Address and Tel.No. �J qa9 ,� sy Y- Type of Building: Dwelling No.of Bedrooms Lot Size 0 t sq. ft. Garbage Grinder (*A0 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(mien.required) 3 3 gpd Design flow provided 33 6 gpd Plan Date FY9 /r ? Number of sheets / ,(I /Re/vision Date Title / ke r rl/,e rleeq Q�' 6 [� of f/ /�✓-- Go4i mis Size of Septic Tank o!< llyd Type of S.A.S. — fre Description of Soil 5.-e AL7 Nature of Repairs or Alterations(Answer when applicable) c/ Z Date last inspected: Agreement: The undersigned agrees to ensure the construct' and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Epeironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boa f ealth. gned Date Application Approved Date D Application Disapproved by: Date for the following reasons Permit No. --e Date Issued t� �� No. C� ^ f ',goy' :;.: 'r Fee /�v `-A TK COMMONWEALTH OF MASSACHUSETTS Entered in computer: T PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ppication for �Digpogar �&pgtem Con0truction Permit Application for a Permit to Construct O Repair( ;`�Upgrade O Abandon( ) ' ❑.Com-Complete System ® nI dividual Components P Y ' Location Address or Lot No. A, leb t,., Owner's Name,Address,and Tel.No. )ta'A%' lob,� ry7/3 _ (o /3� t,J�.,(. /��✓-a/ a� Assessor's Map/Parcel �''� Installer's Name,Address,and Tel.No.,b�.�%1G/u/�'� (.G+✓/� Designer's Name,Address and Tel.No.C/®w t.-' 4!f�v,- Type of Building: q , Dwelling No.of Bedrooms Lot Size al - sq.ft. Garbage Grinder (40 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 c) gpd Design flow provided 33 6 gpd Plan Date ��� /f' 7Q�i Number of sheets ,{/ I /Revision Date Title "" kle 01,.4 /`u ° . (�4/to 1-7 Size of Septic Tank 1.pOGJ �i,G 4/,,.,.j Type of S.A.S. f_V0 Description of Soil 5,,.r Ail 7 y Nature of Repairs or Alterations(Answer when applicable) fir S7`�.a y Date last inspected: Agreement: The undersigned agrees to ensure the constructio 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 oard of ealth. 5'gned Date ,(( r._ Application Approved b' } Date ,j OQ Application Disapproved by: ` ^ Date for the following reasons t, Permit No. ^ -E)�Cj Date Issued THE COMMONWEALTH OF MASSACHUSETTS i BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (4,)/Upgraded ( ) Abandoned( )by /2", �®� , �„yJ7�r✓�/�w at e, /7,4 V j /* lf J,✓ - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ) / l —0?0 dated Installer_DW 21,r1-j. Lraall�srar�`iu� Designer L✓V S'/'b!^e-7,a,!- #bedrooms .2_! �is',rc+� h✓v Approved des -n flow 3li d /� r g The issuance of this pe 'it shall not be construed as a guarantee that the system wi Lf�etio as designed:V f , I r�( / f Date In � _ t No. C9W IF5 '-O,:�b Fee 14161'` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS ligoml 6p�tem Cott truction Permit Permission is hereby granted to Construct ( ) Repair ( Upgrade/( ) Abandon ( ) System located at / y! le 47 ,4 T and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructo1n m t be completed within three years of the da f this p Date 3 7) 7 Approve .)Zy i oio- as _- Commonwealth of Massachusetts Title 5 Official Inspection Form + I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob White Run- Property Address R.J. Day 4, Owner Owner's Nan}B information is Cotuit t/ MA 02635 2/17/20 required for every r 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. Important:When filling out forms A. Inspector Information vim'/ /4 f3g f on the computer, Brett Hickey use only the tab y key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name - key. 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code xa (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey 2/17/20 Ome'.2030.4R.1910:5939 a9'OP 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 has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 < Commonwealth of Massachusetts 1� Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 �+ 6 Bob White Run Property Address R.J. Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State ' Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes:,, ❑■ 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 was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. , Check the box for"yes", "no"or"not determined" Y, N, ND for the following statements. If"not Y ( ) 9 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. P System will ass Y inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts �^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments fi Bobwhite:Run- vv Property Address R.J. Day Owner Owner's Name information is Cotuit MA 02635 2117/20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced. ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i Commonwealth of Massachusetts +� p Title 5 Official Inspection Form I e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob White Run Property Address R.J. Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Bob-White,Run Property Address R.J. Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El or liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ o The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts r- e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (F' j 6 Bob White Run Property Address R.J.Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered."yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑ El Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ 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? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ 0 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 6.13ob:.White.Run Y - Property Address R.J. Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220/GPD Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes [j] No Does residence have a water treatment unit? ❑ Yes ❑. No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes RI No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes 0 No See below Water meter readings, if available(last 2 years usage (gpd)): Detail: 2018=23,000 2019=44,000 Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date t5ins .doc•rev.7126/2018 Titl .P e 5 Official Inspection Form:Subsurface Sewage-Disposal Di p ge sposal System•Page 7 of 18 Commonwealth of(Massachusetts Title 5 Official Inspection Form r_ P. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob White Run Property Address R.J.Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trapresent? ❑ Yes P No❑ Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts p Ti Sewage tle 5Official Inspection Form Susurface Disposal System Form -Not for Voluntary Assessments t ' 6:Bob.White Run _ Property Address R.J.Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 2008 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC El other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints,venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form Jill,• ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 6 Bob White Run Property Address R.J. Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' 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 1 Dimensions: 000 gallon 10of Sludge depth: 2611 Distance from top of sludge to bottom of outlet tee or baffle 4" Scum thickness 511 Distance from top of scum to top of outlet tee or baffle 1319 Distance from bottom of scum to bottom of outlet tee or baffle measured 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.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �^ Title 5 Official Inspection ,Form 1e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6,Bob.White,Rur}-. r;r_,: -:;:.'e9+ S-;:Yi,: 3e�- Cd•`.a-ir-rG�Ekx7.4'-r_n.`..cC1af ,.°?:; '�;"..:�...�t¢ .. w=y. - Property Address R.J.Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: , ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: . Capacity: - � gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J 6 Bob White Run Property Address R.J. Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information '(cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): .0a Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form r- r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob,Wtute:p - v Property Address R.J. Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection. D. System Information (coot.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2) 500 gallons E •leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob White Run Property Address R.J.Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): . The SAS was in working order at the time of inspection. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): NA 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address R.J.Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob White Run Property Address R.J.Day Owner Owner's Name information is Cotuit MA 02635 2/17/20 u-nquired for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet, Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately a it (c A- 15insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 III Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob:White.Run n Property Address R.J. Day Owner Owner's Name information is required for every Cotuit MA 02635 2/17/20 .411 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: M Check Slope ❑ Surface water ❑� Check cellar ❑■ Shallow wells GW is > 5' below bottom of SAS Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record 3/5/08 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: plan on file dated 3/5/08 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob White Run Property Address R.J. Day / t iU"ner Owner's Name f 4 -,rrlation is Cotuit MA 02635 2/17/20 a9 3o.for every City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. FM B. Certification: Signed& Dated and 1, 2, 3, or checked �■ C. Inspection Summary: 1, 2, 3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed �■ D. System Information: For 8:Ti ht/Holdin Tank—Pumping contract attached 9 9 P 9 For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Bob White Run ,M Property Address ' P«J Wells Fargo ,' Owner Owner's Name -Q information is Cotuit Ma 02635 8-2-17 0 required for every e a page. Cityrrown State Zip Code Date of Inspection 65 0 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, v l use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation r� Company Name 374 Route 130 Alf Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI 13640 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 8-2-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal ASystem•Page 1 of V^ ,/ O J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. 13) System Conditionally Passes: Y ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 page. Cityrrown 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): I C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 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 N 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 '/z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 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. ❑ ® 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 0 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �H 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (Actual) _2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 336gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gp ))� Detail 2015-38,000gallons 2016 39,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: 1.Y2 ago Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 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 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is CotUit Ma 02635 8-2-17 required for every page. Cityffown 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: Date of last pump in unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 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 6 Bob White Run M Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New SAS was added to existing tank in 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4'feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3 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: 1000gallons Sludge depth: 6 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Ay Commonwealth of Massachusetts v Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 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 30" Scum thickness 3 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 15" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 page. CityrTown 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: NA 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was in working order at time of inspection with no sign of past backup or 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.): NA * 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallons ❑ 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 was in working order at time of inspection. No high staining, damp soils or lush vegetation were present. Chambers were dry when viewed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 it Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Bob White Run M Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 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: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 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 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 page. Cityrrown 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 4J Front B Al-12'6" 81-28'6" A2.356" 82.2TV A3.53' 83.2T6" 3 Vent' t5ins-3/13 Title 5 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 M 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 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: NO GW 150"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: 2-15-08 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 groundwater elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 6 Bob White Run Property Address Wells Fargo Owner Owner's Name information is required for every Cotuit Ma 02635 8-2-17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 FROM :down cape engineering inc FAX NO. :1508362ge80 Mar. 11 2008 11:57AM P1 Town of Barnstable Regulatory Services Thomas F. Geiler,Director *" Public Health Diz'Ision Thomas McKean,DiretW 200 Main Street,Tjysianis-MA.02601 Fsv:: SOS-79(1-63{ut 0i ice: 508-862-4644 lnctalier &Desxener'Certihcation Form Date: _3 / Sewage,Permit z` o,q Od O Assessor's Mapftrcel Installer: �o' Deer: � - ' ~ Pv. [JV�//'fJJ}K 6 Address. Address: f =0`� 'L,br�'�/di Cam? c� •� •ss issued a pern�i�to install On 3- _ (daza) (ia.5ralle�j based on a design draxvn by Sc�IiC�Stem AZ (addreSS) 1 dated r� I cerd, liat The septic sN-stem referenced above u'a" installed substazxtiaC1 accon Of to the dasi ; u�iaich mad include moor approved changes such a_5 ',ateral relocation. of the distribution box and/or septic tank- I certify that the septic ,stern referenced above was ia-�tal]ed r��ith major changes (i.e. creaser than ]O' lateral relocation! of:ihe SAS or any Vertical relocation of any component of the septic system)but in accordance With State �L, Local Rezulations. Plan revision or cenined as-built by designer to follow- 1. C' (Ins is Si�riature) �c ARNE H OJALA CIVIL No 30792 ( esjng er�s Signature) PLF SE RETUFLT: TO 8ARNSTAi6 E PUBLI Ur I TIC D iON. CERTIfiCA CE OF CQMPI.IA.NCE W111)✓ NOT BE iSSLFD t'.>4T1 ECJTH THIS FORM AND AS-BUILT ARD ARE R£CE)VED BY THE BARN TAB E PUBLIC HE LY H I?1\TiSIdN• T}I.ANK YOU_ r..,.__ .�,c..•;�m�tir.nr_r Certification Form 3.26-04,60c St l(oS e A. yy k COMMONWEALTH OF ASS COMMONW MACHUSETTS �y'�- �_.�� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ���:� ���d, : DEPARTMENT OF ENVIRONMENTAL PROTECTION is Vf— �� RS y r• V Y fi" 3 a 44 R TITLE 5 F ,. OFFICIAL INSPECTION FORM—NOT FOR'.V.OLUNTARY ASSESSMENTS . I( SUBSURFACE SEWAGE DISPOSAL SYSTEM FORMr=m� k, PART A "< t : CERTIFICATION 19 ,Rs u Property Address: 6 BOB WHITE RUN COTUIT,MA 02635 Owner's Name: JAY WALDER 1 its Owner's Address: 6 BOB WHITE RUN COTUIT,MA 02635 RECEIVEDry Date of Inspection: 11/15/01 r DEC 0 6 2001g • Name of Inspector: (please print). 30HN GRACI ,) Company Name: SEPTIC INSPECTIONS TOWN OF BARNSTABLE n 1 Mailing Address: !*A,BOX 2119 TEATICKET,MA.02536 HEALTH DEPT. a 45 + Telephone Number: 508-564-6813 FAX 508-564-7270 g CERTIFICATION STATEMENTn reported i that I have personally inspected the sewage disposal systemiatahis addressperformed based on mytt ain ng and below is � ` 1 1 certify true,accurate and complete as of the time of the inspection.The inspection wasp roved system xr experience in the proper function and maintenance of on site sewage disposal systems.l am a DEP approved j inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).'The system: #e X Passes Conditionally P es '` � �� - . _ Needs Furt valuation by the Local Approving Authority "t Fails �.'" Date: ll/15/O1 Inspector's Signature "�k Approving Authority(Board of Health or DEP)with w�r The system inspector shall submi a copy of this inspection report to.the App g d or greater;thhared e 4," ' 30 days of completing this inspection.If the system is a s the report t the appropriate s e regional office of the has a design flow of lDEP The original should be§ �. inspector and the system owner=shall sub papproving authority. sent to the system owner andcop —Viies sent to the buyer,if applicable,and the app g ,FE 4 ?, } - Notes and Comments L N� � l SPECTION.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO SYSTEM PASSES TITLE V IN �M PROLONG THE SYSTEM'S USEFUL LIFE. r **** report only describes conditions at the time of inspection and under the same different ondit oons Of use at thRt ns,of use'S ? This repo y y inspection does not address how the system will perform in the future under the s a� i P: sir Page 2 of 11 . OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS :. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ; CERTIFICATION (continued) Property Address: 6 BOB WHITE RUN COTUIT,MA 02635 ; Owner: JAY WALDER k Date of Inspection: 11/15/01 ' Inspection Summary: Check A,B,C,D or E/ALWAYS complete all.of Section D �" . A. System Passes: � � t raa X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. 4' 3, Comments: SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: , One or more system components as described in the"Conditional Pass'.',section need to be replaced or repaired.The system, upon completion of the replacement or rePair,as approved by the Board.ofHealth willpass. Y" , � i y Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined" please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced loiQ9, with a complying septic tank as approved by the Board of Health. ;rr A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ' ND explain: n/a s ' n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed. Y pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board ofk" ti�y Health): r _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass * r { inspection if(with approval of the Board of Health): v � } _broken pipe(s)are replaced _obstruction is removed ^> " ND explain: n/a sus k Page 3 of 11 4 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS M ? :- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,R CERTIFICATION(continued) Property Address: 6 BOB WHITE RUN COTUIT MA 02635 Owner: JAY WALDER Date of Inspection: 11/15/01 a C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to .< protect public health,safety or the environment. T. 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: ?i _ 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 F 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that their , : 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. £ r _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private watery supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia ` nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy ,�h of the analysis must be attached to this form. 1*ua t 3. Other: ,a n/a fi w i=. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A' 4,,y CERTIFICATION(continued) di Property Address: 6 BOB WHITE RUN COTUIT MA 02635 f" Owner: JAY WALDER Date of Inspection: 11/15/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: 4n ziq�4, Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspoolrf X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged : SAS or cesspool is _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ' } X Required pumping more than 4 times in the last year NOT to clogged or obstructed pumped Wa. Y gg pipe(s).Number of times } X Any portion of the SAS,cesspool or privy is below high ground water elevation. `k, X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. i X Any portion of a cesspool or privy is within a Zone I of a public•well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes,if.the well water analysis,performed at a DEP }i. ,�� certified laboratory,for coliform bacteria and volatile,organic compounds indicates that the well is free �ins from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to orF _ less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] P4Y' (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 �r 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- Y � K E. Large Systems: ti To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. R: You must indicate either"yes"or"no",to each of the following: ' ' Al (The following criteria apply to large systems in addition to the criteria above) yes no Ar�ry^' • _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a,tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped vrs Zone II of a public water supply well k I# F+r:. I u I 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 threatt gat: under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner `tb , should contact the appropriate regional office of the Department. Page 5 of I 1 ¢ t+ T OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Y PARTB'' :r=� A CHECKLIST L�B� k�ar Property Address: 6 BOB WHITE RUN COTUIT,MA 02635 , Owner: JAY WALDER xF Date of Inspection: 11/15/01 PP k Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No , X _ Pumping information was provided b the owner,occupant,or Board of Health " P g P Y � p '. X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? . ' y a y- X Have large volumes of water been introduced to the system recently or as part of this inspection? � X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? ','V X _ Were the septic tank"manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ 9 X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance... .. �, ��': of subsurface sewage disposal systems,?_ µ:; �R The size and location of the SoilAbsorption System(SAS)on the site has been determined based on: 1 � r Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to-Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] t i y�p p 7V apr � ��• ' s In tr ire e a �a T, T >r r; Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENT �.�.:.• .S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C' ' SYSTEM INFORMATION ' Property Address: 6 BOB WHITE RUN COTUIT MA 02635 Owner: JAY WALDER Date of Inspection: 11/15/01 - FLOW CONDITIONS ' RESIDENTIAL r Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO ^h a +r Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] by Laundry system inspected(yes orpo):NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a fc Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd yF� Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO `& Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a s GENERAL INFORMATION Pumping Records Source of information: n/a4 r Was system pumped as part of the,inspection(yes or no):NO ; If yes,volume pumped: n/agallons How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEMyjb X Septic tank,distribution box,soil absorption system s , _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) g 1„ , _Tight tank Attach a copy of the DEP approval Other(describe): n/ax Approximate age of all components,date installed(if known)and source of information: 15 YRS. Were sewage odors detected when arriving at the site(yes or no): NO ' N Page 7 of I I rV! N OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMx' PART C SYSTEM INFORMATION(continued) �7 Property Address: 6 BOB WHITE RUN COTUIT,MA 02635 Owner: JAY WALDER Date of Inspection: 11/15/01 BUILDING SEWER(locate on:site plan) c Depth below grade:36" Materials of construction:_cast iron _90 PVC Xother(explain): ZO PVC .. � .. Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER s SEPTIC TANK: X(locate on site plan) ' Depth below grade:30" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/ak ° If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31 s Scum thickness:3" ; 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: 15" k ' How were dimensions determined:MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related k to outlet invert,evidence of leakage,etc.): =`s ° SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. Y: E. GREASE TRAP:_(locate on site plan) t,�> ,' '' Depth below grade: n/a Material of construction:_concrete_metal_fiberglass polyethylene_other(explain): n/a Dimensions: n/a Y Scum thickness: n/a a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a ". : Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related s S ^ to outlet invert,evidence of leakage,etc.): . ` n/a 1 ?� f ilk a� ,s� «• Y F) i Page 8 of 11 1 .� F c4 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,2 ,. F.. PART C SYSTEM INFORMATION(continued) Property Address: 6 BOB WHITE RUN COTUIT,MA 02635 t Owner: JAY WALDER Date of Inspection: 11/15/01 , e. F a TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) ' Depth below grade: n/a r . Material of construction:_concrete_metal_fiberglass polyethylene other(explain): n/a y4 Dimensions: n/a Capacity:n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A '{ Alarm level:N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and,.fioat switches,etc.): `• DISTRIBUTION BOX:X(if present must.be opened)(locate on site plan) Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage intor`' ' or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. 4�. 9 t PUMP CHAMBER: _(locate on site plan) guy' b L I4 F Pumps in working order(yes or no): NO ' t. z�N• Alarms in working order(yes or no):NO �, Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): �'ry n/a E� k 1 + F , y ro s � R Page 9 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMK._ PART C '= � SYSTEM INFORMATION(continued) 1 3 = N Property Address: 6 BOB WHITE RUN COTUIT,MA 02635 ` s Owner: JAY WALDER ' i Date of Inspection: 11/15/01 y�p SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) fr . If SAS not located explain why: n/a Type : 1000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a s , n/a leaching galleries, number: n/a t g 9 n/a � n/a leaching trenches, number; length: n/a leachingfields, number: n/a n/a overflow cesspool, number: n/as, n/a innovative/alternative system Type/name of technology: n/afA ; s�4 t.f Comments(note condition of soil,°signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): ` q F LEACH PIT IS FUNCTIONING PROPERLY.BOTTOM IS AT 10'AND.PIT NOW HAS 2' IN IT.-SYSTEM SHOWS NO SIGNS OF FAILURE. ; fPy CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) . X Number and configuration: n/a � Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a s Materials of construction: n/a p=. ' Indication of groundwater inflow(yes or no): NO ` 4 . Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a h . ky- PRIVY: (locate on site plan) Materials of construction: n/a .x J ' Dimensions: n/a Depth of solids: n/a ; = t f Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): kf n/a - r 31, • t k7i n Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 BOB WHITE RUN COTUIT,MA 02635 Owner: JAY WALDER Date of Inspection: 11/15/01 x SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. z' g P Y g P h>r� ;. Locate all wells within 100 feet.Locate where public water supply enters the building. 4' Jj t� ig a 1,13 o 0 1 S 1 r� A19 Ian �. 36 DA 6c r F; d„M.", 'Page 11 of 11 t i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 BOB WHITE RUN COTUIT,MA 02635 Owner: JAY WALDER A, Date of Inspection: 11/15/01 , SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 13+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a y You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED BY AUGER-NO WATER AT 13' BOTTTOM OF PIT AT 10' t , a.. ti�A i•:ay`` .y 4 - (o ' .. L'pC&.T.10 __- _ __ _ _—_ .-SEW6,C,E_ P RMIT UP 1 -__Lt�!ST__QLLER-S_ .►J-�NIE_�-_AD_D.RESS_ __ __. _ __- _ - _ bUILDER_5-_1`!_,(�1�1 DIaTE .PERtvk1T. ISSUED D-4,T_E COMPLIAQ acE ISSUED : �is ' . -----_ e� �s ��v� l �� �� �� "` ^'f� .. - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH __------- -------- OF........................................I.,.............. - ............... Applira#ion for 43ifipm t Wurks Tonotrurli an Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Dis oral System at: ......................... °i _.. h'// ..._� .% .......... c0..l�< Location dress or Lo 0 ..... .rr4 fL ......--•- . -- .•.................. /f -./l / i5!� S' . oW � address Installe Address Q Type of Building Size Lot---.. /..............Sq. feet welling No. of Bedrooms--------------------------------------------Expansion Attic (Hill) Garbage Grinder (�f "Omer—Type of ---- No. of persons---------/----------------- Showers Cafeteria (")d Other fixtures --------...... ...A7/7�S'.-_..... . - ------------------------------------------------------------------------------------------------------- W Design Flow...-. ............ .....gallons per person per day. Total daily flow-.... cG'--------_-_-_--_--.--gallons. P4 Septic Tank—Liquid capacity/a _gallons Length---------------- Width__---.------- Diameter_-----..-_--.- Depth_-_-._-...... xDisposal Trench—No--------------------- Vidth-------------------- Total Length-------------------- Total leaching area.-.--.-_---.-----.-sq. ft. Seepage Pit No-----Z"----------- Diameter... ..._ Depth below inletX.'_,P..:...... Total leaching area------------------sq. tt. Z Other Distribution box ( ) Dosing nk •/dG `z~`' aPercolation Test Results Performe( 4 ......... Date....:............ Test Pit No. l----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water_.-..-------. -------- �rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ - •--- •-------- Descriptio of - l �' `' `-- --------'Z ��y� " =1 � . -- x ------------------------- ----------------------------------------------• .............................................................................................................................. UNature 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— The undersigned fur agrees not to place the system in operation until a Certificate of Compliance has be ued.by e and ofalth. / Signed. ........... .�-/( .-•-.--.... Date Application Approved By--------- ..... . ... ----------------- -r--' ":-------.---' ---------- Date .- Application Disapproved for the following reasons----------------------------------- ------------------•-•-------------------------...--•-•--•. ----------•--- Date Permit No. ... Issued..... Date Lam-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _._ .... .. ...........OF....................................:.......... .... .....------.......------------ Appliration -for Diipniittl Works orks Towitrurtion Vrrmft Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: _ .......... L----- '-?v-t�....._..... .................................lJ rlrJ...Lc.✓oc' Location• dress or Lo�o. 1 = = ---------- = f /j Qrp/ / � .r A/d/dres/s Installed ` Address �• Type of Building Size Lot....._ d..............Sq. feet Dwellings No. of Bedrooms---------------------------------------------Expansion Attic (iyc) Garbage Grinder ( �) wL_ -_ No. of ersons____________________________ Showers L — Cafeteria p.., Otfie`r—Type of Building..___. LL C--_ persons� / ( ) ( } a Other � er fixtures �.--- -----` ----=---------------------------------------'--------------------- •------------------------------------------------ Design Flow_..._._)__�..._.�_lf..__________________gallons per person per day. Total daily flow------- U---'--------------------gallons. W /� � Septic Tculk—Liquid capacity_....:.ud __._g _ _allons Length________________ Width _...._.__..... Diameter Depth...__.__ .__... xDisposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------.-----sq. ft. Seepage Pit No______ ____________ Diameter___j�'-�_._ Depth below inlets.._..__ __ Total leaching area...._..._.....__..sq. ft. 3 - - P - �--• � Z Other Distribution box ( ) Dosing tank//( ) v �-, � ~" Percolation Test Results Performed by.___ ._ ..... -Y -------------- ----------- Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water---------------.._.._:-- (� Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water--.-.._-_-_-___--_.-.__. D Description of it / �,� -- z ` �_. .. -._Z..-/a---- �.-car- . ----------------- -------------- ----------- ---------------- - - x ------------------------ '-----'------- ---------------------------•-•-•------------------------------------------------------------------ .........................._.................................. VNature 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— The undersigned fur wr)agrees not to place the system in operation until a Certificate of Compliance has be7gy7ued,bXy�the rd of alth.J/ Signed_ //� � r ff/ Date Application Approved By--------- - -•----- ---L!/;!!1- ------ ---75'----------- Date Application Disapproved for the following reasons:...............•-------------------------------•-•-•-••---------------••-----•------------•-•-------•-------•--- ..-••-•••••--•--•••--•----•-••----•----------------------------------------------------------------------._ ------------------------------------------------------------------------------------------ Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA H ............OF........&....................................... ........ .................. Trrtifirate of Toutplitturr T IS TO CERTIFY, at the d• idu�j Sewage Disposal System constructed ( ) or Repaired /t Installer j G� (/C J u---�c� Gv v�d' -1S�•• IN... �''k' -•--•---------- has been installed in accordance with the provisions ofrtiele XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit N � ___.., Z_ ______________ dated..7 '......._ ................ THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD )QF HEAL �J ' ..........OF....... GG�Ll/o%..................... ......................... v No-------------••--'•=--•. r FEE ___...-•---••---.... BitivgV orkii Qla trur f rrm _ � , - Perm) Ion}s�ereby granted -------•---- . ...................... .. ...... -I't. to Co ct ) or R . aIr (��l vi' al Sew e asp s I System J- at N L.=/--.-1 :. --•----•-•-!/`..l.Lt-s-----...... ..�---.... . _. .. -----, St-eet - 2 � j as shown on the application for Disposal Works Construction . er it N .'_ ._. J ated-------------------'--••--.._...• -•-- ---• •-------------- -- --••• .................... Board of Health . DATE--------------------------------------------------------------------------•----- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS it `OJ ki.�. 44 01 40 t tb }'_. � ,{'. ;�•�_,_e__.� �1��sue-- i 1 p•o /�.�.-.�`'.��n# /�.�'©,h�'C�1�`�'�7 /�L'J C1..1�.� .G aC�y"/D.lf� t s�ss�/� � SA�v-3'uT ,�r9�'N57/9•�3/,�' .^,if�.S.S' . . Cct"lUTEI�v/LLE /`SASS . . I SYSTEM PROFILE NOTES Q TOP FNDN. AT EL. '7i;.I3 ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO WAW ACCESS COVER TO WITHIN 3 OF FIN. GRADE 1. DATUM IS APPROXIMATE NGVD ACCESS COVER (WATERTIGHT) TO A WITHIN 6- OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING 75.0' MINIMUM .75' OF COVER OVER PRECAST 2X SLOPE REQUIRED OVER SYSTEM .4 74.4 ' RUN PIPE LEVEL OR GEOTEXTILE FABRIC 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. EXISTING FOR FIRST 2' 3 MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO ;. "EXISTING 1000 *71.15' 71.48 - 10 *71.4'f GALLONsI TIc TANx B FLE 70.8 70.63GAS ' 0 Q Q Q Q Q Q Q 5. PIPE JOINTS TO BE MADE WATERTIGHT. ocus 1te R� Route 2$ :: .. 0 70.48 ppQQ Q 000Q o o� DEPTH OF FLOW = 4" 6" CRUSHED STONE OR MECHANICAL Q Q 0 Q p Q p Q p 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH I_ o TEE SIZES: COMPACTION. (15.221 [21) 2 Q p Q Q 0 0 0 a 0 0 68.48' MASS. ENVIRONMENTAL CODE TITLE V. O o INLET DEPTH = 'ESL_' 3/4" TO 1 1/2" DOUBLE WASHED STONE 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO ouTLEr DEPTH = 14" BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. ( 1 x SLOPE) (-1 X SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. FOUNDATION EXISITNG SEPTIC TANK 35' D' BOX 17' LEACHING 5•48' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND LOCUS_ MAP PERMISSION OBTAINED FROM BOARD OF HEALTH. *THE -INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM MIN. SCALE: 1" = 2,000't LOCATIONS OF ALL UTILITIES AND ALL SEPTIC TANK SIZE AT 1000 GALLONS AND 10. CONTRACTOR SHALL BE RESPONSIBLE FOR .CALLING BUILDING SEWER OUTLETS AND ELEVATIONS ITS SUITABILITY FOR RE-USE BOTTOM TH-1 EL. 63.0' DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION ASSESSORS MAP 10 PARCEL 27 PRIOR TO INSTALLING ANY PORTION OF OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO SEPTIC SYSTEM COMMENCEMENT OF WORK. LOCUS STRADDLES GP & WP OVERLAY DISTRICTS LEGEND 11. EXISTING LEACHING -FACILITY SHALL BE PUMPED AND REMOVED. 100.0 PROPOSED SPOT ELEVATION 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED +100.00 EXISTING SPOT ELEVATION LEACHING FACILITY. 10 -o PROPOSED CONTOUR 100 EXISTING CONTOUR SYSTEM STEM �ES�. � LOT 19 r'o SEPTIC DESIGN: (GARBAGE DISPOSER Is NOT ALLOWED ) ,�66g BENCHMARK 21,000 SFt �o� DESIGN FLOW: 2 BEDROOMS (110 GPD) = 220 GPD EDGE CONC: BULKHEAD USE A 220 ,..GPD DESIGN FLOW ELEV. = 75.74' -` SEPTIC TANK: 220 GPD ( 2. ) 440 v° -�.. _. F L_=C1SE A 1000 GALLON SEPTIC TANK 16 LEACHING: SIDES: "'30 t 9.83) 2 (.74) = 118 TEST. HOLE LOGS - �\ . �� BOTTOM: 30 x 9.83 (.74) = 218 \\ DAVID FLAHERTY R.S., SE2755 \\ PATIO ENGINEER: EXISTNG wkREs TOTAL: 454 S.F. 336 GPD WITNESS. DONNA MIORANDI, R.S. \\ �\ ST., DWELLING GAS °N USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR FEBRUARY 1.1, 2008 \\ !` ` TOFNDN = 76.78' METER DATE: 6 EQUAL) WITH 2.5' STONE AT SIDES, 4' AT ENDS AND 5' < 2 MIN/INCH \\\ �5 BETWEEN UNITS PERC. RATE _ -� ����'\ CLASS i SOILS P# 12099 \\ \ ELEV. ELEV. \ \as N 1� APPROVE[ DATE. BOARD OF HEALTH MA on 75.5' 75.5' 1�1_ \\ L N \ BENCHMARK O \\ COR BRICK LANDING S6 OQ \\ >6 STONE \ ELEV. 77.24' \\ C`'.s`. ., H-1 / DRIVE / 10YR 3/2 10YR 3/2 \\ 0 '� a. x 12" 12" O �\ _� TITLE 5 SITE PLAN B B \\\ TH-2 `� .a j BUSHESOF \ // LS LS � \\ E LIN 50„ 71.3 48 71.5 WHITE �u 10YR 5/6 " 1 OYR 5/6 \ ` / se BOB BITE RUN \\ Y 1f // pR) (CO UIT) BARNSTABLE., MA PREPARED FOR PERc C �' 2�` BORTOLOTTI CONSTJ MS MS 5' REMOVAL OF UNSUITABLE SOIL \\ 17 TOM MATTON REQUIRED AROUND PERIMETER OF LEACHING FACILITY, DOWN TO ��\ DATE: FEBRUARY 15, 2008 - 2.5Y 7/3 2.5Y 7/3 WSUrrITH CLEANS MMEDOILD.. SAND.EPLACE O H OFssq off 508-362-4541 � AItNI H ARNE rym fax 506 362-9880 N H. CMLOALA A No,26� down cape en gin eerin g, Inc. 150" 63.0' 120" 65.5' Nb. 792 NO GROUNDWATER ENCOUNTERED Scale:l"= 20' 4�0���� s �.� C/l//L ENGINEERS u LAND SURVEYORS 0 10 20 30 40 50 FEE'. DATE ARNE H. OJALA, P.E P.L.S. 939 Alain Street - YARMOUTHPORT, MASS. DCE #08-024 ., 08-.024 BORTOLOTTI_MATTON.DWG (DDF)