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0024 BRANDYWYNE COURT - Health (2)
t I I — !e lit- No. —0-2-0 Fee -to BOARD OF HEALTH TOWN OF BARNSTABLE 0[ppricatiou _for Yell Cou5truchou Permit Application is hereby made for a permit to+� Construct(vj Alter( ), or Repair( ) an individual well at: a.y t3 f 4 r,d%j W t-,R., CT- CO l U t 1 'Location-Address �/ R Assessors Map and Parcel Cp/wJwry YOLIKG'Gn.� i2( IJ/'gn�Yfw,lwe LT t^OI(A1� Owner Address fpc•u Nis Jt /1avc T , 4PeM 0-)6 Y� Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Z/ Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certific5te of Compli nce h een issued by the Board of Health. Signed Da e Application Approved By - Z ate Application Disapproved for the following reasons: Date Permit No. A� Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(,f, Altered( ), or Repaired( ) by De.u,�is � Ll Installer at i)K /v,Y,t�f/G:�tw has been installed iA accordance with the provisions of the Town of Barnstable Board of Health Private Wel70214 ection Regulation as described in the application for Well Construction Permit No. W2,W Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. Fee !•�^ , BOARD OF HEALTH * . t TOWN OF BARNSTABLE Ytcation ,Ior Derr Coiigtruction ermit b Application Is Hereby made for a permit to Construct(ti), Alter:'( ), `or Rep"air O an Indlvldual.well at �} Location-Address„ Assessors Map and Parcel , #{ C iou /;(-xej .fY� �-w LT tlf—,` Owner Address �C�+ n✓iS �<mti.ucr� C,/�IIP/ �S� Crv+n[,STN"T/O& nvt? /��C Rc—� /1-�61 Y j y Installer-Driller v J Address w• ''' Type of Building _ F r Other-Type of Building No:of Persons " Type of Well y Capacity Purpose of Well Agreement: _ The,,undersigned agrees to install the afore described individual well accordance with the provisions of the -Town Board of HealtWPrivate Well Protection Regulation The undersigned further agrees not to place the, well in operation until a Certificate of Comp/lance hasfbeen-ssuedby therBoar'd'of Health Signed / _ b .Pis•sr sYr. �—� J U It ,Date Application Approved By �� z .Dale I ' Applicat>on Disappro e`dtfor the following reasons: 1 f •, ,� � Date ,V. Date ' ",.ds��'�i�"-- 2.u."4' �-�sil:`:�="`"�`.i�:�ii.� -'� ..' s' -�i: �:.•i'L�s'"'.;y."" rr'r+•,�a. :�asr �� .-s _'''.. _ --- --`a:_..._,,. �e BOARD OF HEALTH TOWN OF BARNSTABLE :f certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(v), Altered( ), or Repaired( by DeN�/S Sc0 bVh�P/ ? p+ Installer,, } �I' .' . x..� �. r• v F I�, � At Y % fG ac�s%.`r,.�r,z°`c has been installed in accordance'with the provisions of the Town of Barnstable Board of Health Private Well P�r�/otection Regulation as described in the application for Well Construction Permit No. Z-l'- Dated �X8 I l ,, - l THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. ` Date Inspector 7 T - ._.r. _.,.. , _.. ._ , ._ ., - BOARD OF HEALTH ""` TOWN OF BARNSTABLE Ivell CoTY.5truction Permit No. `"_ Fee Permission is hereby granted to � Too nmip X Installer y, j to r Construct(!); Alter( ), or Repair;( ) V ;an mdivldual.well,at Street as shown on the application for a Well Construction Permit No. r�'� Dated Date Approved By ( �' �4�».iym.+'.i-, -.. ,,. „ e-,t. t y4' .m,•<. ...� ,g., . ar:.'r..� ... t:s :r-. ...�.d.,.. ,.,+,.,-.,lr,;.;iiw.w.•a-�.�FSt�,a '1nrd5t'haY ':rk+t.t-F.eflrtt!y�'b6�+navy:s'.�wCsM.�lt;s�y'ti�"fi%k I _ - rrf..rr'��.��..+rl.u�. r r...-r..,�.a..r-. lf...a.aar,r.4.....+5t°' • D St<.N po;r.x ro,1�.tGL� G4AilIbY - � "lr�R�l * t►c� 43 050�o 56.fP.tirt "" sna Yayti • eq5 r *A • q90 cP+a Woo 44t. ftt { +vAr�1h A¢GA s ef 54,8► G� , _ , q, pT101J»y iill '� OeLWA C?•( + a -� c»•; • r' itr rt.... ` cl ', , ��` ' � IL • � ...lr..�.. .'�+ t y �. .� l.�.�• w 1I �`' . 4,f t� +f• �Iry 1 `- 1_ � rl Mf n i j ,�;• j 4r.�f�of # ; is ' k ' '!, : <, , PL t ``i w t3u21019 14 3�a 'T�eST ���fdw aim RPM MA PIT Am Ilb 01 fix' �� 4tbril► 1111 h� ,w t�' . .1 r � c• .� � + `;.�� ; � r.� CI�ZTtF1C1��'`, r3•oT lays ►2 try g� , iue,.. _ i s T14 J E (.*TU 1T talc' VATE4. � , • �'��K�:1t, _P�.a,w.t .tea ., t cc+rrt�t T1iATou�Za sY'�o�l sWow.i i:...t- t .®.�. aa%Adow G��cPi•Y; warty t�aa. it �.tw�� r. { A►rD :4�R"BAG�L R�1'iW�J�NAit1�►T$ O!� T41�. ;.� :61 :CTV tY Stvi Cg3aLw2, rVA,$ 1�.'•YC�f' ON '��L: WY61 N161►tT _ CiK LWi., i fMA•�j. 4u=Vw 4 tMr• J/ TOWN OF BARNSTABLE LOrAi10`T o2`E �Zt�t� la,w��.. Cb,,>� SEWAGE # VILLAGE QZ7V I C ASSESSOR'S MAP &LOTS-$' '" `: r INSTALLER'S NAME&.PHONE,NO. i-hciceet 'C043%V— SEPTIC TANK CAPACITY � vNO• LEACHING FACILITY: (type) (size) 9—V)(S NO.OF BEDROOMS UII.D R OWNER C-` Nk-4- `'. � `'t PERMITDATE: _ '� COMPLIANCE DATE: J Separation Distance Between the: , Maximum Adjusted Groundwater Table and 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 leac -ng facility) Feet Furnished by f Z �G e ----- _. nSSSESsoMMAPNo-- T�. No. 1 PARCEL N0: �,r f�� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for Zt!5po!5ar *p5tem Construction permit Application is hereby made for a Permit to Construct( or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tql.No. TC)v Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. O'L-6 Q Type of Building: Dwelling No. of Bedrooms 2--, Garbage Grinder(� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil O'2 '� I T- ature of Repairs or Alterations(Answer when applicable) f '>111c i 2 5Do Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board.of Health. Signed Date t G Application Approved by _ Application Disapproved for the following reasons Permit No. �P " � Date Issued N�` Fee �., L✓ ... 1 . THE COMMONWEALTH OF MASSACHUSETTS `Y, PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE., MASSACHUSETTS' 01ppricattov fo i ogaY *pgtem Construction hermit Application is hereby made for a Permit to Construct( orRepair•( )an On-site Sewage Disposal System at: Xf, " Location Address or Lot No. ! Owner's Name,Address and T I.No. LOT r72 E+s qqjr t`^vG. Tvc.� • a��p�w�va� �nJ�T s��.- � �. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. V_La(t 0-004 Sa 1�4 raJw`S w�ti- OL6 p Type of Building: Dwelling No.of Bedrooms 2... Garbage Grinder(N9 Other Type of Building. ,- No. of Persons Showers( ) Cafeteria( ) Other Fixtures s Design Flow gallons per day. Calculated daily flow gallons. P1an�;Date Number of sheets Revision Date Title Description of Soil 4``Z-- # S�� �► ~ e0 ! S+' - r j. ature of Repairs or Alterations(Answer when applicable) IN1S Xk 1 a�� S �. ('�'�� I -� ( 14•to� rw-fl 'i`FtvZ a eft X 6> >�'c��-aa rev ssyc s wJ W s 7DW A Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by this Boar of Health. Signed o-- Date oId 9 L Application Approved by Application Disapproved for the following reasons, -~ , .i Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( <orrei�r-ed_/re_p!laced( )on by H t e-�-. 00,01,N— for. M Q 'T"0 J r_-�'*y -,. at t4-L' W%#J �bJ (Ur' C tTv•"�' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 4 070 0 dated Use of this system is conditioned on compliance with the provisions set forth below- No. �ZP Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwioogal *proem Construction 30ermit Permission is hereby granted to N«�_ tl to construct((u r pair )an On-site Sewage System located at �`t �.�t/tr► �rd CoOj T' 1 F and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: w- qf/ Approved by V � m -� a- a I t / • � � 1 o D - oz 2 s y£ � 4 01 GIINNY t a4 3 L?- coi Cur�CC��I, Nct t � + � 0-5r6 p31 .t t �Gvsg fill in pose cutoues with Azek Or strip and pitch inAzek - gray shinglej a rows deckI4 fastened with 1 "c®r8W hidden scweav8 a4Zelt whit trademark pow <aorm with top rail and island caps and 11 rows of feency . ., a �t �Y dofYn r.� � � +.. x cable . Est 14' trimboard to face deck frame also r teps to lend on 6'u 16"x stair risers and 'blue worts slob „ StP°In�rs OP 4� -e- I I / I d d f ` / _1 VV� t a � � Z FW— u i fig. •x� a F z o �v CL . N Y � rr r: a. hi J71- ,� s t -. Ilk Av- _ -s'f _•`'.-�+�'�...,,ti. ix;. 4 � ram' � .,'% _ }F i }�� �„�•��`` � }� .�.F i� 5 ice?A _ a w•. ...'^q•^ J' ....tea i L Or'C A T 10 N #I� $ EW � o2 A E PERMIT NO. V&LLAGE INSTA LLER'S NA i ADDRESS r 8U11DER OR W ER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED _..... ------ — TOWN OF BARNSTABLE LOCATION d-`E SEWAGE VILLAGE 'C�yV ti ASSESSOR'S MAP&LOTS`'- �� INSTALLER'S NAME&.PHONE NO. i-k e VJA SEPTIC TANK CAPACITY t �� � vN� LEACHING FACILITY: (type) (size) 3p�� 3` unrD NO.OF BEDROOMS `Z-- �...Y R OWNER C-`RNJ +L- �•`c-� -+� PERMITDATE: 4 13"'�to COMPLIANCE DATE: Separation Distance Between the: - '® Maximum Adjusted Groundwater Table and 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 leac g facility) Feet Furnished by / l�!. r 16 1 a � � 5� LOCATION SEWAGE PERMIT NO. VI.LLACE � r INSTA LLER'S NA & ADDRESS BUILDER OR W ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED lam _ .a f��� - � y�/ � i � ,�-U L �� 4 Y � !� _r a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1��...._.--a................OF......-. I 1 p Applir ation for Diopos al Works Tonstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ystem at: 7 2- ------ _ ..�:..... .--�- •-•••....................�...... ......•-------•----•--------------••....... .................- Loca' n- dress or Lot No 34 .......... ._. _.. ._.... s_-= Owner ••Address a - �. ............................. Installer Address Type of Building �ff Size Lot...... A. ..........` et l a aDwelling—No. of Bedrooms.........."r..............................Expansion Attic (46 Garbage Grinder X) Other—Type of Building No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------- -------------:-.....-•-------------•••-------•-••-•-•-••••. W Design Flow........�.�;5?�................................ per person per day. Total daily flow-------4..�'.�............................gallons. WSeptic Tank—Liquid capacityr0 _gallons Length................ Width................ Diameter-_.____..___---- Depth............. x Disposal Trench—.No......... ..... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage 2Diameter.._.;���___..._. Depth below tnle �? g q. Z See e Pit No... . _._(� ,,� �(ry ) .. ........... Total leaching area...��.�--�..s ft. Other bution box Percolation r1Test Results Performed by. ............�'.r!.1............ ............................... Date...�.� :_.......__. aTest Pit No. 1................minutes per inch Depth of Test it.__.__._........._.. Depth to ground water........................ �rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil------=�' > ........ - ......... x U -----------------------------------•-----•-------------••---------------••-•••----------- W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --- -----------•---------•--.....----------------------------------------------------------.._._..--•--•....--•--••-----. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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 oar M11 . g �,` ,i ned. .---.�®... - -- -•------•......---•- dh to _ Date�i J Application Approved By-•-••• -er ._..... . .... � 1. .v................ .../-__�` --. Date Application Disapproved for the following reasons:-------••---------••••••••••••--•••-----•-------------•••------•--•-•-•-•••-------•••-•.._.........---••------•. ............................................•----------------......--------••----•-•-•---------......---•---•---------•----•••••••-----•-------•--------------••-•-••-----------•••--•--•---•••......--- Date r r•, . Permit No....................................-- Issued........1.�- .� 7� r, ------------- ----•--•-•-------•.... Date _.. No.................. Fmc.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t5hem S M 9 k h-,. ............................. ......0.F.....................I......I........ ..................... ............ A Vftrauou for %qpoiial Works, Tonstrurtion "amit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal:, z4gkA4 7z. ......................................................... ............................................................................................ -O - Si.Lo s upa i0vowt mcor LotA),&XA4 blej 4: . .................................... ..&....................................V.............. A............ .......................P M 149 04A69ss)'1LJ ..... ......... ......... . ... ..................................................... ......... .......... -------"I...... ......... S ........ ...J.... Installer A Address Lot......1 4...........jq. f et A Type of Building Size .#... Dwelling—No,- of Bedroom ......+ .........................Expansion Attic Garbage Grinder X) P-.4 04 Other—Type of Build i�,,g ................... No. of persons............................ Showers!'(' Cafeteria Op�S fixtures ...............................................................w.......................i............. .................................. Design Flow.__t........................ --gallons per person per day. Total daily flow__._._4 .....................gallons. Septic-Tank,—Liquid ........capacit;r gallons Length................ Width__.............. Diameter__-_--_`______- Depth.. ...... Disposal Trenich—No. Widt�a-------------- Total Length.......__ ........... .........Total leaching area_.._______ .,,..sq. ft. .11.............. Seepage Pit No.......... --------- Diameter.....e............... Depth below mlq... ............ Total leaching area... ..........sq. ft. Z Other Distribution box X) Dosi 04 1 /�.2 S. - .. Percolation Test Results Performed by...YA---)........ .................I'—Date.... ................................ ------------------- Test Pit No. I.....:..........minutes per inch Depth of Test ' it.______............. Depth to ground water--___-_______-__-__ --. fi, Test Pit No. 2 ............minutes per inch :Depth of Test Pit--------------4_.... Depth to 2,round water---- ................... . .......... --------- —,/—-------- Q Descr' iptioh of S`6il ......... .............lam, ...!?------ . ......m ..........�2----------......... -------------;4 ................................w.................................................................I......................................................................... U ---------------------------------------------------...................................................................................................................................I................. U Nature of,,Repairs or Alterations—Answer,, when applicable................................................................................................. ...........................................................I ......................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT L71, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until,,.a Certificate of Compliance has been the oa /hj. V _V� .- -.?/. .......... igned_ ... ..... . . . ............................................... ApplicationApproved By......... ....... .... ... ........................ ................ .................... ................... Date a. r the following .............................................------ Application Disapproyed for .......................................................... .......................................................................................... ......................................................................................................... Date PermitNo.................. Issued.,... ....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD- OF HEALTH .............. ........................0 F.......�►�*�I1C...a uti.i....... ................................ 4 Ttrtifir il ate of p aurr THISAJ63�a 4irTIFV Tha&'.theind idual Sewage Disposal System constructed ()4) or Repaired ► P*Uj by........................ - ------_--------------- ................................................................................................................................... N Inst4les, 94ANISVOML Cot.) - . .................................................................... ......................................................................................... has been installed in accordance with the provisions of T 5 of��hAtate Sanitary- ode as described in the application f�"is_posal Works Constructi6n Pern___ ......................... dated._0...............& ..................... ,THE ISSUANC-EYOF THI S C TE sHAL -NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .......Z ........................................... Inspector......... ........DATE.--......Id...... °% %% .......................................I'll f �:.THE COMMONWEALTH .OF%MASSACHUSETTS BOARD OF HEALTH **T- �LP41_11A AeP4Sr&t;Pk Ar. ........................ ..............................:.......................................0 F............. No......... ...1..... FEE........................ i ern 1. Vorkv tong .. ................Permis�ion hereby granted--...X ............................................................................. to Const ct. e io Re' d* D� -an In ivi ual Sewa jjisjjQsal System A0 4 :T A k)/AJ ft. aw,oe I y atNo....b.......:........................ .............................................................................................................................. I " Street as shown on the application for Disposal Works Constructioenrmit Dated.4� 0 .......................... ........ .. .................................. Board of Ht'<w— DATE............. �P-7t' ..................................................I................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS D SIGN Sl LIQ LE FAM I L� - 3 8E3�ROotit ;f. pt►��.� t=ww . Ito e $ +Ir�°�o•dRSG.P.Tl. i ,, E .,_ �';�� _ �� SEPTG TANK + dq5 �� V,1S1PCY5,AL PIT V q` IOCO 6A(, 4.71 o GPD GoTTo#A AREA• '►gSF , :. �: 1. Ala o. -t�l TbTA�• L7pilfirN ri i t f ?t'. ,1 a ; I i W, 2 MAJ otZ F ij l '" -� .)"'_'1."a +, i 5 �. , I�•ND iV�//I��t- -i O .`L) , f_�. .-. `.. . OF A9, f r A, r. i ) �� �N + � t I i i— i t 1 i Q A 2,1048 oil IST TeST zs�-r<Q Tod.Fib+`too' . ; •� E-G-* q2 77, TA ZR7TT�YTIC�7 4•pi1L t Ss Lc 4 rnpE t..i Bolt. 1 i4i . x'r , ( - I i� �� �• ._t. i.t i �: .; � �V� -�:. � i � � � ! ice` _ - I coo GAL. i V q0 qt�p {s i f 1 � ' ` �• I ' r i � Pi T 77� 1 I t "{ ,,Y; I,.VI '� f .. . j. � Mo„ r w�Tu E i 'GT0W4 �Ro FI I2 6TU IT �L) _� �c� 'x40"f--. 00 a (�o ,TE2 .F;':: �A.t. t TLt 'ESZ�cl= i 1 t Cat'YIFY TKAT' �'"� I'ou,Ala QTIDW SWCMA J II "ER rm N Com PL-`f S w i r H na& StvE,u"ohL 1-4 I A"D SETBACK %ZSQu1e&wtrauT; of TLM ff wkjw of BAR�JSTA'81 ._ _ DATE. �` Q�`1S•T� QED L4N� �Q��� TKIS Pt-sW ►y t.toT BA,SED`ot.i AIJ: a1�KiTP.t�ME►tT 0erTE•EVtt." •.. ;A4A.CPS. ; 6utCvwf 4 TWE ot=6=S41';. 'Stet `t.b �alo�' `T&C `4JSgo To: 'PETM1ZmIWE. i.oT AP�.tcl�t.a'Y'• f ' , TOWN OF BARNSTABLE LOCATION LA C©-VE . SEWAGE # VILLAGE QZ7U ASSESSOR'S MAP & LO 07 INSTALLER'S NAME&.PHONE NO. PhcY- , SEPTIC TANK CAPACITY j uNP LEACHING FACILITY: (type) z u�aaS (size) i- NO.OF BEDROOMS Z . UII..D R OWNER PERMrrDATE: 6 -3"'� COMPLIANCE DATE: Q �� Separation Distance Between the: . Maximum Adjusted Groundwater Table and 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 leac ing facility) Feet Furnished by ` G � . O � O � � � - a �°' p f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/15/14 Inspe Signat 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. 24 Brandywyne Court(system 1)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system 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: n/a ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 24 Brandywyne Court(system 1)-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 CityrFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: n/a 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 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. 24 Brandywyne Court(system 1)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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: n/a D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® 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. 24 Brandywyne Court(system 1)-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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. 24 Brandywyne Court(system 1)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 24 Brandywyne Court(system 1)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4+ Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 1 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)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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: Last date of occupancy/use: Date Other(describe): n/a 24 Brandywyne Court(system 1)•03108 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•.Rage 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: regular pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1978 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 24 Brandywyne Court(system 1)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owners Name Cotuit MA 02635 5/15/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 12 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6"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: 1000g Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle >12' Scum thickness trace-1/2" Distance from top of scum to top of outlet tee or baffle >2„ Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured 24 Brandywyne Court(system 1)•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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.): n/a 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): n/a 24 Brandywyne Court(system 1)-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owners Name Cotuit MA 02635 5/15/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box in aveage condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 24 Brandywyne Court(system 1)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 I Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M SVOy`Ba 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ 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.): Leach pit"C"was excavated and there was 6"of effluent in it, stain line 2'from the bottom of the pit, clean sidewalls, no indication of past backup 24 Brandywyne Court(system 1)-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): n/a 24 Brandywyne Court(system 1)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM ,� 24 Brandywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Citylrown State Zip Code Date of Inspection D, System Information (cont.) Skefh Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at 16ast two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. l `io c, 3a 3� 24 Brandywyne Court(system 1)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,a 24 Brand_ywyne Court (1 of 2 systems at property) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: per elevation of home 24 Brandywyne Court(system 1)•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 115 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: . Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/15/14 Inspe s igna ur 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. 24 Brandywyne Court (system 2)•03/08 Title 5 0 icial Inspection F ubsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system 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: n/a ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 24 Brandywyne Court(system 2) 03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Brand ne Court 2nd of 2 systems) YwY ( Y ) Property Address P Y Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a 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 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. 24 Brandywyne Court (system 2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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: n/a D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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. 24 Brandywyne Court (system 2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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. 24 Brandywyne Court (system 2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owners Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ 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)] 24 Brandywyne Court (system 2)-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 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)): Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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: Last date of occupancy/use: Date Other(describe): n/a 24 Brandywyne Court (system 2)-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 CityrFown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: regular pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1996 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 24 Brandywyne Court (system 2)-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-20 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500g Sludge depth: trace Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace Distance from top of scum to top of outlet tee or baffle >2,, Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured 24 Brandywyne Court(system 2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owners Name Cotuit MA 02635 5/15/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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.): n/a 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): n/a 24 Brandywyne Court (system 2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 24 Brand ne Court 2nd of 2 systems) YWY ( Y ) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box in very good condition Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 24 Brandywyne Court (system 2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 Flos ❑ 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.): Chambers are dry at this time,no indication of past backup I 24 Brandywyne Court (system 2)•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): n/a i 24 Brandywyne Court (system 2)-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. V C. 24 Brandywyne Court (system 2)•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M , 24 Brandywyne Court (2nd of 2 systems) Property Address Toukan Owner's Name Cotuit MA 02635 5/15/14 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Per elevation of home 24 Brandywyne Court(system 2)-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 LOrCAT SEW E PERMIT NO. VlL LAC E INSTA LLER'S NA i ADDRESS l 1r v B UILDE R OR o1w, MER DATE PERMIT ISSUED �� _ �� DAT E COMPLIANCE ISSUED lam Z_ 7 6a