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HomeMy WebLinkAbout0036 BRAMBLEBUSH DRIVE - Health 36 Bramblebrush Drive Cotuit P - A = 040 090 f {{ r 9 1�If 1 0WIN O BARNSTABLE LOCATION J� ��A(`� `�U S �r• SEWAGE# VILLAGE C U V l ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) P, (0 X(0� (size) d NO.OF BEDROOMS 3 OWNER R.f(fDIV PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet FURNISHED BY J - (Al SJ- t 3 y 3 ( 01 33 c `� q° ;L Commonwealth of Massachusetts a1-f0 -0?0 p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w�. 36 Bramblebush Drive Property Address 4 ' Nile Morin Owner -Owner's Name ' information is required for every Cotuit V/ Ma 02635 3/21/2020 page. City/Town State Zip Code Date of Inspection i-e 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 I qq(.0 on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co Company Address Centerville Ma 02632 Cityrrown State Zip Code rem, 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com 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 3/21/2020 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 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 property located at 36 Bramblebush Dr Cotut is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. This report does not gurantee how system will perform in future and only describes conditions at 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 determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally I 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): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) i 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): i, 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 Commonwealth of Massachusetts _ Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. Cityrrown 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 ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >r 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y2 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. Cityrrown 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 ® ❑ 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 h❑ ® s 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 1 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® 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 ® No information in this report.) 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: unknown Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Canons per day(gpd) Basis of design flow.(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ 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: 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635, 3/21/2020 page. Cityrrown 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: original system 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 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.): Joints in good condition, no leakage, vented through roof. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Bramblebush Drive V Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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: 1000 gallons Sludge depth: 5„ Distance from top of sludge to bottom of outlet tee or baffle 3 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. 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 r' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: i ❑ 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): 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <.; 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. Cityrrown 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): 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.): Distribution box was functioning as intended. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts J Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): * 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: 1x1000 ❑ 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 Form:Subsurface Sewage Disposal System•Page 13 of 18 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. Cityrrown 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.): leach pit was found with 1' standing water and a stain line 8" below inlet. 12. 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 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 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ry 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. Cityrrown 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 1 Z 0 3 _ V A( i ZL/ RZ i_)' A3 G 3 33 OH 27 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y rY 4i 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. 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: pate ❑ 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Bramblebush Drive Property Address Nile Morin Owner Owner's Name information is required for every Cotuit Ma 02635 3/21/2020 page. 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. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 18 of 18 zar ous Materials Inventory Sheet Checklist ` Date . �—Physical Street Address-Check database to ensure it exists Z�_—Working Phone Number Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) c_---- Storage Information - location of storage, how long is storage for? If none, note that. I---Disposal Information -where and who? If none, note that. Applicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and explain it -Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS NAME OF BUSINESS: r CI �Iis / S-7-rQPF ) BUSINESS LOCATION: �� INVENTORY MAILING ADDRESS: -;U (,fr(U{, p„ I T�� ��3s TOTAL AMOUNT: TELEPHONE NUMBER: ` p- 6)1�u CONTACT PERSON: l' EMERGENCY CONTACT TELEPHONE NU BER: 52 8 6q 1j MSDS ON SITE? TYPE OF BUSINESS: �,�� t4hlke 1 clekin- ✓u" INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) WNEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) ya Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you. must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form:at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: �I� f Fill in please: �r,n! 'u• j APPLICANT'S YOUR NAME%S: Oar d s4>,ATM'* TM' � BUSINESS YOUR HOME ADDRESS: � � rrr�'4 1R� J 57 �JF )ITo ir!tf e TELEPHONE # Home Telephone Number - 1 0 NAME OF CORPORATIONN: NAME•OF.NEW BUSINLSS CMewt TYPE.OF BUSINESS NO IS THLS A HOMEOCCUPATIOIV?•' - APO RESS:.OF BUSINESS 1 ( . c = MAP..PARCEL NUMBER;:4 U When starting a new business there are several things you,must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO ISSIO ER'S ONCE This individu I h s r�fi��Jda8pe mit requirements that pertain to this type of business. MUST COMPLY WITH HOME:OCCUPATION' RULES AND REGULATIONS., FAILURE TO MENT y on igrp 1 _,"✓IDLY MAY RESULT IN FINES.. X. : 2. BOARD OF HFLTH This individual has n informMal e r�re irements that pertain to this type of business. Authorized Si nature** MUST COMPLY WITH ALL COMMENTS: NAZA UUM S. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** . COMMENTS: I 4�/ 4 1'. 7 M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Cityffown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any .,fay. Please see completeness checklist at the end of the form. Important: When filling ou A. General Information on jW % /�forms on the /�(//��� )J� computer;use 1 Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name r� P.O. BOX 145 Company Address CENTERVI LLE MA 02632 Cltyffown State Zip Code 508-420-4534 S14297 Telephone Number License Number U-1 co B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the Z11 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 c:a sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Titie 5;(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by.the Local Approving Authority 8/25/11 Inspector ignature 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fora.=Not for Voluntany Assessments 3 BRAMBLEBUSH DR Pr,operty Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Ciryili own State Zip Code Date of inspection B. Certification (cunt.) 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: 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 A etermined,,'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 lS2king and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): uini6•uwiio Tice 5 01%i iai lnspEedur,Funin:Subsurface Sewage aspusal s iefi,•Page 2 ui 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is required for COTUIT MA 8/25/11 every page. Cityffown 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 leveler+^r 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•09= Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts R.wR—Om Title 5 Official ec Ins i p t on Form Subsurface Sewage Disposal Syste;n Form n Not for.�o!unta y Assessments Sys tern BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Cltyi I own State Zip Code Date of inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and.nitrate nitrogen is equal to or less than 5 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 n Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ N Liquid depth in cesspool is less than 6"below invert or available volume is less than Yz day flow t5ins•09N8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ( Title 5 Official Inspection� p Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments '� ' 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8125/11 every page. ufyf 1 own State Zip code Date of inspection B. Certification (cunt.) 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. ❑ Z 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 afe triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either`yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered'yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. f5ins•09M8 } Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwea[th of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntar y ry Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Uyfrown 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 El 2Were any of the systern 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? Z LJ 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): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forma Not for Voluntary Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Ci yrown State Zip Code Date of inspection D. System Information Description: ACCORDING YO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK D- BOX AND LEACH PIT Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): HOUSE Detail: VACANT Sump pump? ❑ Yes ❑ No Last date of occupancy: UNKNOWN Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ . No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No ` Water meter readings, if available: f5ins•09/08 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal system Form. Not for o! n+ary Assessments 36 BRAMBLEBUSH DR Properly Address ZAPPALA Owner Owner's Name information is required for COTUIT MA 8/25/11 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ' ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: 0 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5Official Inspection Form . Q = Subsurface .rage Dtsposa!System Forma Not for Voluntary Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is required for COTUIT MA every page. Cityf lI own 8/25/11 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: APPEARS TO BE ORIGINAL Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet 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: 1000 GALLON Sludge depth: VARYING BUT LIGHT t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 L i Commonwealth of Massachusetts Title 5 Official Inspection Form WSubsurface Sewage -Di�pc$a Voluntary Form Not for Volunta^ Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA moma Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Crtyi-I own 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 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING EVERY 2-3 YRS 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•09)08 Tide 5 Official Inspection Porte:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forrn=Not for Voluntary Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is required for COTUIT MA 8/25/11 every page. Cltyffown State Zip Code Date of inspection D. System Information (cunt.) 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 m .( 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•09A8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsur fa-e Sewage Disposal System Farm=Not for Voluntary Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Crtylrown State Zip Code Date of inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09iD8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts WNW Title 5 Official Inspection Form MYSubsurface Sewage Disposal Sysxm Form=Not for Voluntary Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Cityrown State Zip Code Date of inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): PIT WAS DRY WITH STAINING 4 FT PIT HAD SOME ROOT INFILTRATION BUT NOT SEVERE 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 tsins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Se—, Disposal System Foam-Not for Voluntary Assessments V 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is required for COTUIT MA 8/25/11 every page. Crtyi I own 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•09N8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts ? Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo^;;-Not for Voluntary Assessments 36 BRAMBLEBUSH DR Properly Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Ci yrrown 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: U hand-sketch in the area below ® drawing attached separately t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 w ` Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for:voluntary Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. Cityi 1 own 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: NONE AT 12 FT 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: 8/25/11 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09iD8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts o Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo-m Not for Voluntary Assessments 36 BRAMBLEBUSH DR Property Address ZAPPALA Owner Owner's Name information is COTUIT required for MA 8/25/11 every page. CIryi l own 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•09JOB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 1 R T WN O BARNSTABLE LOCATION rAt^ bU s �'. SEWAGE# VILLAGE C C V 1 ASSESSOR'S MAP&PARCEL "7 o INSTALLERS NAME&PHONE 110. SEPTIC TANK CAPACITY aW LEACHING FACILITY:(type) P (p X{p'' (size) QOD NO.OF BEDROOMS 3 OWNER �dbl�S PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching.Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY101 p j0� �A Poi� , �..� A . ttp://town.bamstable.ma.us/Assessing/ffMdisplay.asp?mappar=040090&seq=1 8/25/2011 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 36 Bramblebush Drive Cotuit, MA 02635 Owner's Name: Georze Brooks Owner's Address: Date of Inspection:. May 10, 2007 Name of Inspector: (Please Print) James M. Ford r Company Name:. James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at.this address and that the inform ationlreported, below is true,accurate and complete as of the time of the inspection. The inspection was performed based oy training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DAP ' approved system inspector pursuant C to Section 15.340 of Title 5(310 MR 15.000). The system: 4�. -n ✓ Passes t�a , Conditionally Passes u� Ne s urt her Evaluation by the Local Approving Autt�io ity rJ Fa* s ® r, � rn Inspector's Signature: Date: M 17 2007 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 DER 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 how 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 11 ` OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Bramblebush Drive Cotuit, MA Owner: George Brooks Date of Inspection: May 10, 2007 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 15.3.03 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 removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Bramblebush Drive Cotuit, MA Owner: George Brooks Date of Inspection: May 10, 2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to detennine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier;if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply.well**. Method used to detennine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fonn. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Bramblebush Drive Cotuit, MA Owner: George Brooks . Date of Inspection: May 10, 2007 D. System Failure Criteria applicable to all systems: You must indicate either"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 ''/2 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. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 31.0 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 System: Y To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is,within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of apublic 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 36 Bramblebush Drive Cotuit, MA Owner: George Brooks Date of Inspection: May 10, 2007 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping infonnation 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: 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: 36 Bramblebush Drive Cotuit, MA Owner: George Brooks Date of Inspection: M 10 2007 P �' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): apd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 2124184-per as built card Were sewage odors Aetected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Brainblebush Drive Cotuit, MA Owner: George Brooks Date of Inspection: May 10, 2007 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by.a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 aQ 1. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Convnents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs ofleakgge. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recoinmendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Bramblebush Drive Cotuit, MA Owner: George Brooks Date of Inspection: May 10, 2007 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Continents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): No solids were present. PUMP.CHAMBER: None (locate on site plan) Pumps in working order(yes or no); Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 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: 36 Branzblebush Drive Cotuit, MA Owner: George Brooks Date of Inspection: May 10, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 QaL) 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.): The leach pit had Y of liquid on the bottom. The scum line was 4'up from the botton2. There did not appear to be any signs of failure.. The cover was 2'below. The bottom to grade was 9'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Bramblebush Drive Cotuit, MA Owner: George Brooks Date of Inspection: May 10, 2007 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. z SAIk a. �Or 01 T7 y 3 101 33 c Y q° a�7 10 Y Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Bramblebush Drive Cotuit, MA Owner: George Brooks Date of Inspection: May 10, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- feet Please indicate(check)all methods used to detennine 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: USZ71Q Barnstable topographic and water contours maps, the maps were showing approximately 30'+1-to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 � d �J q qj w a . _ ,p �� � � � �- -'� � �� Z �. v � ��; .ti { � ,.r.. '�V � � � ,._ � / �-�� �� o� _� a�� Z �: s i G z v f s rn CA r r p � S"z 9G = N e• ou 4A N � C en C o N v � N z �a v LA ni R t - jz II.. No.... .:?::......... y Fxa...��5.•�............. ^ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......Town.......................OF......... arnstable------------------..........................---•- Applir atiou for Dispati al Works.Tonstrurtinn amit Application is hereby made for a Permit to Construct ( X) or Repair. ( ) an Individual Sewage Disposal System at: ........Lot 22,,...Brarnblebush Dr.-,---Cotuit, Ma. ................. Location-Address or Lot No. ...Cedar Acres _Realty_.,Trust .......2.4 Great Pond Dr. ,__.S.__.Yarmouth,,___Ma. Owner Address W Cedar Acres Realty _Trust 24 Great Pond Dr. ,___S. Yarmouth, Ma. a ....................•.... ... •--.........----•-..... ...... ---•...•••• Installer Address Type of Building Size Lot.....21_t_4 0 0_______Sq. feet UDwelling—No. of Bedrooms......I...................................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -----------------------------------•-•--•••••. W Design Flow............5.5...........................gallons per person per day. Total daily flow.....33.0 gallons. WSeptic Tank—Liquid capacity 10 0 Ogallons Length................ Width........_._..... Diameter________.___.... llepth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) DosipZ tank ( ) 1­4N.ormari Grossman P.E. Sept171982 a Percolation Test Results Performed by-•---------•-- •---•................. . . Date_...................................... a Test Pit No. 1..............minutes per inch Depth of Test Pit.....1 ...__.__. Depth to ground water----none 0i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ......................................................... , sof1..••24"-144......sand-----•.........................•----•---•----- Descriptionof Soil .....-•-•------------------...._.........---.....---••-•---------------------------------------------•-----•---------•--••--•-•-•--•-...........-•_.. x x -----•-•----------------------------------=----•-••---- -------•---••----•-•----•--••••••--•••••-••-----•-•••-•------------------------•-•---•------------------•---....-------•------•---------•------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS...1 5 of the State Sanitary Code—The undersigned further agrees not to place th system in operation until a Certificate of Compliance has been iss d by the b rd f healt Signed ---...-•-- •....�. .................. Date. Application Approved By........... . ...... ....'1, ' `A-••.•••... Date Application Disapproved for the following reasons:........................................................ ....................•---•--•---------•--......_...-•-----•---------------------------...---•------•-----.._..............•-•-•••••-•-------------•--•••--•......••••-----•-------•-------•-•--•.......... Date PermitNo.......•--•-......... _. Issued...-------•---------•-•---•--._...----••---...------ ---------•-••-••-•••--•--............Date No..... `2- v - Fss.... 1................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town......................OF.........Barnstable Appliratiun for Dispunal Works Tonstrurtiun Vamit Application is hereby made for a Permit to Construct ( )6 or Repair { ) an Individual Sewage Disposal System at: ........3�ot 22,�...Bramblebush Dr. , Botuit, _Ma_. __. ................. - -- ----------•-----------............-----......................... Location•Address or Lot No. ___Cedar Acres Realty_.Trust ,__„__29 Great Pond Dr._r..S. Yarmouth, Ma. .......... ..._. ... •-• -• ........ O ner Address W Cedar Acres Realty Trust _ 24 Great Pond Dr. r. S. Yarmouth, Ma. a ......................................................_ ...... .... ---- Installer Address UType of Building Size Lot._.._2190......Sq. feet ►-� Dwelling—No. of Bedrooms......3...................................Expansion Attic ( ) Garbage Grinder ( ) 'k Other—T e of Building No. of persons............................ Showers Pk YP g ---------------------------- P ( ) — Cafeteria ( ) d Other fixtures --------------------- W Design Flow............5 5...............14 v 0 gallons per person per day. Total_daily flow..........0..............................gallons. WSeptic Tank—Liquid capacity._...-.-....gallons Length................ Width................ Diameter................ Depth......_......... x Disposal Trench—No..................... Width-................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin tank1.4 ( Sept171982 Percolation Test Results 2 Performed by.. Orma rossman P E. Date ...-•-•---- ----- -----------------1 2-T..................... none 14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--------__.-_•-.-----_-. fXq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a rrz- w-- -- v.. H , p g O Description of Soil••........-w ---- ToBm_�... ..... .siiliso�Ll 4_ _._I � �arid .. . ---------•...............................•--•.....-------•-•- "� - W Z. ----------------------------------------------------------------------------------------------------------- --------------------------------------------•-------...................------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•------•-------------------•-------•----.....---•--............-•------------...--•--...............-------•-•--------------------....--------•---•----------------•--•-----.....-•-••-------•.....-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L I':L, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... -••----•.................. Date - Application Approved By........... Date Application Disapproved for the following reasons-------------•---------------•--•----•--...----------•--------------------------•-•-••--•-- ......--.....------ ......---•--••-•••-••---••---•-••--•--••------••....-•--•--•......--•-----•-----••--..........•-•--•-----•-••-•-•...............•-••----•--•-•-••--•------••••--•••••----•-----••---•••---•••••••••----- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ..................OF..................................................................................... Trriif iraft of Tome ianrr THIS IS TO CDRTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.............. r- - .....�-------------------------------------------------•----.........---------------.......----------....----------------------------------........ Ins alley has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... ......•. dated................................................ THE ISSUJ N E OF THIS CERTIFICATE SHALT. NOT BE CONST D AS A GUARANTEE THAT THE SYSTEM 14NI F NCTION SATISFACTORY. DATE.......- y / ................................................ Inspector.-• -- ' ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ...................................................... No....*A-21.3 FEE.2Z ........... Disposal Works TDuns#rnrttiun antic Permission, s hereby granted................•---------.......--••--•-------•-----------------------------------•---......--•---•---•-•-•---•....--•-•-•-••--......---...... to ons 1S r r C t ct o e ai an In vldual e a e is al System '�ot 2 , r �e�ush r. , C�o` z , pia. y atNo....................... = Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... Bo o FIealth DATE---•-•--------------•--........./0; ..................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS v ILA+ ®�� ti Commonwealth of Massachusetts Executive of Environmental Affairs DEP� , . 6 19g6' t Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 013 ramble B ush ffbad. Cotuit M a. ��. Address of Owner: Mrs Hickey (if different) Date of Inspection: 04/19/96 Name of Inspector: Michael D eD ecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system -X-- Passes --- . Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s Signature: Date: 04/22/96 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Bramble Bush Road, Cotuit Ma. . Owners : Mrs Hickey Date of Inspection : 04/19/96 INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM PASSES: --x-- I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If "not determinated", explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration , or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). ----- broken pipe(s) are replaced ---- obstruction is removed ----- distribution box is levelled or replaced ---- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ----- broken pipe(s)are replaced ----- obstruction is removed �i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : 63 Bramble Bush Road, Cotuit Ma. Owner : Mrs Hickey Date of Inspection : 04/19/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require'further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING INAMANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING INAMANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. --- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. i . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 B ramble B ush, Cotuit M a Owner: Mrs Hickey Date of Inspection : 04/19/96 D) SYSTEM FAILS (continued) , -- 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 over- loaded or clogged SAS or cesspool --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. --- Required pumping more than 4 times in the last year N 0 T due to clogged or obstructed pipe(s). number of times pumped --- Any portion of the S oil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I 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 ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Bramble Bush Road, Cotuit Ma. Owner: Mrs Hickey D ate of I nspection : 04/19/96 E) LARGE SYSTEM FAILS: The followingcriteria apply to large systems in addition to the criteria above : PP y 9 y The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : --- 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 I I of.a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 63 Bramble Bush Road, Cotuit Ma. Owner: Mrs Hickey Date of Inspection: 04/19/96 Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flaw rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components, excluding the Soil Absorption System, have been located on the site. --x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 63 Bramble Bush, Cotuit Ma. Owner: Mrs Hickey Date of Inspection: 04/19/96 RESIDENTIAL: Design flow : 9P 0 gallons Number of bedrooms : o a Number of current residents: o Garbage grinder (yes or no) : ►�� Laundry connected to system (yes or no): yr s Seasonal use (yes or no) : do Water meter readings, if available: N�� Last date of occupancy : "� COMMERCIAL/INDUSTRIAL : Type of establishment: Design flow : gallons/day Grease trap present: (yes or no) Industrial waste holding tank present(yes or no) : Non-sanitary waste discharged to the Title 5 system (yes or no) : Dater meter readings, if available : Last date of occupancy : Other: (Describe) .......... . ................................................................................... Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informatio System pumped as part of inspection (yes or no) :....:!O. ........ if yes,volume pomped : .................... gallons Reasonfor pumping :............................................................................................................ v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Bramble Bush Road, Cotuit Ma. Owner: Mrs Hickey Date of inspection: 04/19/96 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) --- Other (explain)........................................................................................... APPROXIMATE AGE of all components, date installed (if known) and source of information A��..a ......AC.'.� ................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no).:.. .. SEPTIC TANK : (locate on site plan) Depth below grade: ..�. ... Material of construction: ...K. concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: S 1` >.`S... Sludge depth :....k.'.'....... Distance from top of sludge to bottom of outlet tee or baffle:..... ?................ Scum thickness:.....©.n.......... Distance from top of scum to top of outlet tee or baffle: ............ .......... Distance from bottom of scum to bottom of outlet tee or baffle:.....I.G.'.`............. Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakUe,.,.etc. .. ....... ..... ...`...�..�...�. ....t�t...¢k,. .s►��r rr,r -....z. �. ... o . .�. T2, i..u .L....tN. .... ......... f a ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Bramble Bush Road, Cotuit Ma. Owner: Mrs Hickey Date of inspection: 04/19/96 GREASE TRAP : ......%...... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FR P........other(explain).... .......................................................................................................................................... Dimensions:............................... Scum thickness:...................... Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................ TIGHT OR HOLDING TANKS:.....!... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FR P..........other (explain).......... .................... Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ........................................................................................:................................................... C r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 0 Bramble Bush Road, Cotuit Ma. Owner: Mrs Hickey Date of inspection: 04/19/96 DISTRIBUTION BOX:.*.'s (locate on site plan) Depth of liquid level above outlet invert:.f'.v..........l Comment: (note if level and distribution equ I evide ce of o sds carryover, evidence of leakage into or out of box, etc. `'.�.f,�}�F ..,..t ....� ........................... ................................................................................................................................................ PUMP CHAMBER:.....P.O.. (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ . ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SASI....� 5....... (locate on site plan, if possible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: .................................................................................................................................................. ................................................................................................................................................ Type: leaching pits, number: ...►. . ek.l leaching chambers, numb. .r:........ leaching galleries, number:........... leaching trenches, number , length:................ leaching fields, number, dimensions:................... overflow cesspool, number:.......... Comments: (note condition of soil , signs of hydraulic failure, jevel of ponding, co dition of ve etation, etc.). .. ... aQ ..F.......................... a v J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 63 Bramble Bush Road, Cotuit Ma. Owner: Mrs Hickey Date of inspection: 04/19/96 CESSPOOLS:...I�.�1..... (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: ..................... Indicator of ground water: .................... I inflow (cesspool must be pumped as part of inspection) ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................ ................................................................................................................................................ PRIVY : .... L1.... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . ................................................................................................................................................ ................................................................................................................................................ f r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Bramble Bush Road, Cotuit Ma. Owner: Mrs Hickey Date of inspection: 04/19/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. . i 0 3 LA Lk DEPTH TO GROUNDWATER: Depth to groundwater35...feet Method of determination or approximative: ... q...... .....AD7 KS....�A Ia S.. K:S.�►nT ..... �1.. 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