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Home My WebLink About0049 BUCKINGHAM WAY - Health s 49 Buckingham Way Cotu it 021 040 I f Health Master Detail Page 1 of 1 Logged In As: TOWN\riynnj Health Master Detail Wednesday,December 16 2015 Application Center Parcel Lookup Selection Items Reports Parcel ` Septic I Perc I Well I Fuel Tank Parcel:021-040 Location: 49 BUCKINGHAM WAY,COTUIT Owner:ZENOPOULOS,CHRISTIE&JACQUELINE B Septic changes have been saved. Septic 1 L New Septic... Permit number: Permit type: Select type vm..._.."" Complete system: ❑ 1771 Issue date : Complete date �•, r Septic tank size: 0 Type/Size of SAS: Installer: Select Installer v Card on file: ❑ I/A service type: Select service v Innovative/Alternative Technology type: Select IA type Variance date : .1M.Abandon complete date : Abandon permit number: Repair deadline date : 10/1/2014 12 Repair notification date : 10/1/2012 Keyword: Comments: Created for septic inspection = Delete Septic Inspection 10/6/2010 Inspection B/12/2004 New Inspection.. Number Inspection Date Inspector Result 5834 10/6/2010 Judd,Richard CP(Conditional pass) Received Date Comments A hatch is to be installed on the wool, deck to gain [---Delete Inspection-___ access to the inlet portion of the existing 1000 gal A septic tank. Recommend that the septic tank inlet icover be raised to grade (below deck) . Deck support 2, 4!r—� Ipost to be moved off the top of the septic tank. 2 L years. JNF Y . i , Save Septic Changes ," Return to Lookup 07 i sir b http:Hissgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=021040 12/16/2015 D Ln ' off- Fit 0 0 u7 M Postage ``C� ►� " C3Certified Fee C C3 Return.Recelpt Fee Postrna&,l C3 (Endorsement Requtred) _ ,fie( -Here C3 Restricted Delivery Fee w� r-I (Endorsement Required) M U&,)J Total Postage&Fees $ '� C —0 O n Mr. Christopher Zenopoulos /(]Jl/', P O Box 132 - Cotuit, MA 02635 Certified Mail.Provides: f (es,enay uu l zooz eunr'ooee o:j sd © A mailing receipt } Q A unique identifier for your mallpieoe° �� • A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. 'a Certified Mail is not available for any class of international mail • NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof`bf delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3e11)to the article and add applicable postage to cover the fee.Endorse mallpieoe"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mallpiece with the endorsement"Restricted-Delivery".. d If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt Is not needed,detach and affix label with postage and mail. L' IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. - , SECTIONCOMPLETE THIS ON DELIVERY ■ Complete items 1,2,,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X ,� ❑Agent ■ Print your name and address on the reverse / ❑ drysses so that we can return the card to you. B. Recgjved�Prifiied Name) C. Dat of livery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? 1. Article Addressed to: If YES,enter delivery address below: ❑ho Mr:'.Christopher Zenopoulos P v Box 132 Cotuit, MA 02635 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Y 2. Article Number t t:,t.:: (Pansferfrom service/abeq ' i 7?0 U6 i 0 811 {0 0 0 0 i i 3 5 2,4 6758 I . Ps Fort 3811,February 2004 Domestic Return Receipt 102595-02-WIS40 UNITED STATES POSTAL SERVICE Fr t- tFo--s, CI'ass Maid PS gt IM .'g.1 • Sender: Please print your name, address, and- IPA irAN Town of Barnstable Public Health Divisioi!.�., 200 Main Streety Hyannis, MA 0260 Ic,) ca '40 Town of Barnstable Barnstable f T HE raw �O �i 1� Regulatory Services Department A"m'ocac" II BARNSTABLE)a "ASS. Public Health Division AJfa a, 200 MainStreet, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3524 6728 October 1, 2012 Mr. Christopher Zenopoulos P O Box 132 Cotuit, MA 02635 RE: Inspection of septic system prior to sale of house ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located 49 Buckingham Way, Cotuit, MA was last inspected on 1/06/2010, by Richard Judd, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) . The following conditions/repairs are required per the direction/conversation with Health Director Thomas McKean on 1/8110. • A hatch is to be installed on the wood deck to gain access to the inlet portion of the existing 1000-gallon septic tank. • Recommend that the septic tank inlet cover be raised to grade (below deck). • Deck support post to be moved off the top of the Septic tank. You are ordered to repair or replace the septic system within Two (2) years from the date you receive this notification. 1 . Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE OARD OF HEALTH gKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\conditionally passed\49 Buckingham Way,Cotuit.doc SHE_ Town of Barnstable . Barnstable pp Taw 0- 1�MI�ICB City nAa. E � Regulatory Services Department 0 SS 039. Public Health Division rEo MAC a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3524 6728 •, October 1, 2012 Mr. Christopher Zenopoulo, U P O Box 132 Cotuit, MA 02635 RE: Inspection of septic system prior to sale of house ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 { ' The septic system located 49 Buckingham Way, Cotuit, MA was last inspected on 1/06/2010, by Richard Judd, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) . The following conditions/repairs are required per the direction/conversation with Health Director Thomas McKean on 1/8110. • A hatch is to be installed on the wood deck to gain access to the inlet portion of the existing 1000-gallon septic tank. • Recommend that the septic tank inlet cover be raised to grade (below deck). • Deck support post to be moved off the top of the Septic tank. You are ordered to repair or replace the septic system within Two (2) years from the date you receive this notification. ----� Failure to repair/replace the se tics stem within the deadline period will res tin tune°1 p Y p � 1-,11 '�. enforcement action. PER ORDER OF THE OARD OF HEALTH cKean, R.S., CHO . Agent of the Board of Health Q:\SEPTIC\conditionally passed\49 Buckingham Way,Cotuit.doc jr. Barnstable of Town of Barnstable AFAl11C116aCfii Regulatory Services Department i I BLF- 6BAT�r . ,�� Public Health Division �ArfD M 200 Main Street, Hyannis MA 02601 2007 m Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7008 3230 0002 5178 2312 , February 22,2011 Estate of Frederic P. Claussen C/o Cape Cod Five Trust &Asset.Management P. O. Box 20 Orleans, MA. 02653 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 49 Buckingham Way,Cotuit,.MA was last inspected on 1/06/2010,by Richard Judd, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5.(310 CMR 15.00) due to the following: The following conditions/repairs are required per the direction/conversation with Health Director Thomas Mckean. • A hatch is to.be installed"on:the-w'ood deck to_gain accegs tothe inlet'-portion of-: ethe existing 1000-gallon septic tdnk:;>. Recommend that the septic:.tank inlet cover be raised to grade(below.deck)7 r Deck support post to be moved off.tlie fop.of.tlie.septic-tank. You are ordered to repair.or replace the septic system within T_wo (2) yeas from the date You receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. P ER OF THE BOARD OF HEALTH Jam. r 7a ean, R.S., CHO r Agent of the Board of Health V USPS.com®-Track&Confirm https://tools.usps.com/go/TrackConfirmAction.action English Customer Service USPS Mobile Register I Sign In Ja Vsps. oi w Search USPS.com or Track Packages Quick Tools Ship a Package Send Mail Manage Your Mail Shop Business Solutions Track & Confirm You entered:70083230000251782312 Status:Delivered - Your item was delivered at 9:48 am on February 24,2011 in ORLEANS,MA 02653. Additional information for this item is stored in files offline. 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OFFICIAL USE r-q Postage $ "' Certified Fee \\�\S MAI'Li Q Postmark � Return Receipt Fee �\ O (Endorsement Required) Here t►9911 j Restricted Delivery Fee E3 (Endorsement Required) m I'f1J Total Postage&Fees $, f m t ICP Il CD Sent To o Stake o F'aederre A P• C aN sse A $treat,Apt.No. p P• cle G'aPe C's� rve T�iist' IQSSe't' r,- or PO Box No. R/I Qcc a/A C q City S --ZIP+ �t -- -• l 0:3PX 20 Orl rQn VIX 3 :rr rr. Certified Mail Provides: a A mailing receipt " o A unique Identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Malle. o Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate.return receipt,a USPSe postmark on your Certified Mail receipt is required. a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,please present the art!- cleat the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000.9047 COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sig Item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse x ❑Addressee so that we can return the card to you. B. Received by dn6d Afame) C. D e of livery i ■ Attach this card to the back of the maiipiece, a or on the front if space permits. D. Is delivery address different from Rem 11 ❑ es 1. Article Addressed to: _,.vac ---,, enter delivery address below: ❑No Estate of Frederic P. Claussen C&o Cape CodZ ve T�iust & Asset Management ' P. 0. Box 2:0 ;I Orleans, MA.-02653- - -- ilfled Mail ❑Express Mail ❑Registered ❑Return Recelpt for Merchandise ❑Insured Mail ❑C.O.D. c 4. Restricted Delivery?(Extra Fee) 2. Article Numb (Transfer fro&sen4ce label 7 0 0 9 3a 3 O v od g PS Form 3811,February 2004: ; I Domestic Return Receipt 2-M-i540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box` FTwn of Barnstable I � I Public Health Division 200 Main Street r Hyannis, MA 02601 i I i �°p SHE Town of Barnstable Barnstable P Regulatory Services Department ;e'ca�j + BARN STABLE, MA ' - �.t639. Public Health Division aj ♦� m A�fD MAf a. 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7008 3230 0002 5178 2312 February 22, 2011 Estate of Frederic P. Claussen C/o Cape Cod Five Trust&Asset Management P. O. Box 20 Orleans, MA. 02653 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 49 Buckingham Way, Cotuit,MA was last inspected on 1/06/2010, by Richard Judd, a certified septic inspector for the State.of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The following conditions/repairs are required per,the direction/conversation with Health Director Thomas Mckean. • A hatch is to be installed on the wood deck to gain access to the inlet portion of the existing 1000-gallon septic tank. • Recommend that the septic tank inlet cover be raised to grade (below deck). • Deck support post to be moved off the top of the septic tank. You are ordered to„repair or replace the septic system within Two (2) years from the date you receive this notification. j Failure to repair/replace the septic system within the deadline period will result in future enforcement action. P ER OF THE BOARD OF HEALTH �- i, ean, R.S., CHO Agent of the Board of Health Commonwealth of Massachusetts ° Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Buckingham Way, Cotuit MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is Orleans required for every MA 02653 January 6, 2010 page. City/Town State Zip Code Date of Inspection Inspection results.must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms , on the computer, use only the tab 1. Inspector: key to move your ' cursor-do not Richard Judd key the return Name of Inspector Y Richard Judd, R.S. „b Company Name P.O. BOX 1315 Company Address Harwich MA 02645 Cityrrown State Zip Code 508-896-9316 S19584 Telephone Number License Number B. Certification 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: ( fi ❑ Passes ® Conditional) Passes Y ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority January 6, 2010 Inspector's Sigrfa fure 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 49 Buckingham Way, Cotuit MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. 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: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", ``no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or-the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ® Y ❑ N ❑ ND (Explain below): see attached page 2A. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Richard Judd P.O Box 1315 Harwich, MA 02645 Regmered$aneairian Office: 508-896-9316 Sepbc&jphmDesqmFax: 508-896-3330 g juddsepticservice(a_com cast.net Sol Evakmfimis&ksbAa6on anent January 12,2010 49 Buckingham Way Cotuit, MA R Assessor's Map:21 Parcel:40 Addendum page 2A. SYSTEM CONDITIONALLY PASSES The following conditions/repairs are required per the direction/conversation with Health Director Thomas McKean on 1/8/10. 1. A hatch is to be installed on the wood deck to gain access to the inlet portion of the existing 1000-gallon septic tank. Recommend that the septic tank inlet cover be raised to grade(below deck . 2. Deck support post to be moved off the top of the septic tank f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 49 Buckingham Way, Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailin • P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):' ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N. ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M s 49 Buckingham Way, Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if,the well water analysis, performed at a DEP certified laboratory, for 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 El ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary tary Assessments M 49 Buckingham Way, Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owner's Name information is required for every Orleans MA 02653 January 6, 2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any,portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 101000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts ti. r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not f 9 p Y or Voluntary Assessments 49 Buckingham Way Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Mana ement Mailin P 0 BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. 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 El ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not .available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 1101 gpd x#of bedrooms): 330. 700 gpd provided t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 49 Buckingham Way Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address . Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailin • P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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)): 09= 195 gpd 08= 176 gpd Detail: water consumption includes yard irrigation use_ Sump pump? ❑ Yes ® No Last date of occupancy: current 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 49 Buckingham Way, Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records:., Source of information: BOH: 8/23/04 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): (Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �., 49 Buckingham Way, Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussery C/O Cape Cod Five Trust&Asset Management: Mailin • P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Per Barnstable Health Department: Sewage Permit 79-272 Certificate of Compliance dated: 8/27/79 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.3 +/- feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water> 10' from exit line. feet Comments (on condition of joints, venting, evidence of leakage, etc.): There were no observed signs of backup or leakage within the cellar at the time of the field inspection. Septic Tank(locate on site plan): Depth below grade: 2 to 4" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000-gallon septic tank per application and design. If.tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 8.5' long by 4.8'wide by 4.1'flow Dimensions: line. Sludge depth: 311 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Ili Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 49 Buckingham Way, Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailin • P.O. BOX 20 Owner Owner's Name information is Orleans required for every MA 02653 January 6, 2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 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 17" How were dimensions determined? sludge judge & measure tape. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The liquid level was observed at the 4" PVC exit line pipe invert. The inlet portion of the tank was not accessible because a wood deck is located above tank. A single deck support post is positioned on the septic tank. Per 1/8/10 conversation with Health Director the septic tank requires access over the inlet port and the support post is to be removed/relocated from the top of the tank. There were no observed signs of backup, leakage or hydraulic failure within or above the septic tank at the time of the field inspection. The septic tank did not require maintenance pumping at the time of the inspection. 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Buckingham Way, Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene El other(explain): � Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes, ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Buckingham Way Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010. page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0`' Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Surface to top/cover of D13-5/1-1-10 (21"X 13"): 10". The box contains one inlet line and one outlet line (both are 4" PVC). The interior of the box was clean and unrestricted flow was observed between the septic tank, distribution box and leaching pit. The structural integrity was intact. There were no observed signs of solid carryover, leakage, backup or hydraulic failure within or above the box at the time of the field inspection. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.. 49 Buckingham Way, Cotuit MA Assessor's Map' 21 Parcel 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailin • P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. Cltyrrown 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/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS =6' by 6' pre-cast pit with 2.0'+of sidewall stone (6'deep by 10'wide in a square design configuration). Surface to top/cover of pit: 1.75'. Surface to floor of pit: 8.60'. The interior of the pit contained 1.83' of measured standing liquid. Sidewall staining indicators were measured 4.20' above the floor of the pit (1.60' below inlet line pipe invert). There were no observed signs of breakout or hydraulic failure within or above the SAS at the time of the field inspection 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 l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ,••''� 49 Buckingham Way, Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 . January 6, 2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 BUCKINGHAM WAY 0 w O v 0 B M 33.25' A M DECK sUde door trim 1 support post 2 3 0 10.0 SWING TIES - r A B 1 30.0' 20.7' 2 38.2' 31.5' 3 49.8' 36.5' SEPTIC COMPONENT LOCATIONS JuDD SEPTIC SERVICE Rick Judd, R.S. P.O. Box 1315 LOCUS: 49 Wa Buckingham Harwich, MA 02645 9 Y COtuit, MA 508-896-9316 PREPARED FOR: RET/INSPECTION MAP: 21 PARCEL;40 JOB NUMBER: 10-001 SCALE: VI _ 309 DATE: 1/6/10 SHEET: 1 Of 1 © 2010 Richard Judd Registered Sonitarion Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` 49 Buckingham Way Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 49 Buckingham Way, Cotuit,-MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is Orleans required for every MA 02653 January 6, 2010 page. Cityrrown 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: >4.0' below floor of SAS. 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: 5/7/79 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) z Accessed USGS database-explain: - USGS topographical information with Barnstable groundwater contour map: attached You must describe how you established the high ground water elevation: Method 1: Per approved design plan: the proposed floor of the SAS to the bottom of the dry test pit provides a 2.8' dry separation distance. Method 2: Approximate USGS surface elevation: EL. 50.0 +!- Approximate SAS floor elevation (-8.6'): EL. 41.0+/- Groundwater contour elevation: EL. 15.0 +/- Estimated separation distance below SAS: 26 0' Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 49 Buckingham Way, Cotuit, MA Assessor's Map: 21 Parcel: 40 Property Address Estate of Frederic P. Claussen: C/O Cape Cod Five Trust&Asset Management: Mailing: P.O. BOX 20 Owner Owners Name information is required for every Orleans MA 02653 January 6, 2010 page. Cityrrown 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 FLOOR EL, 41.0t III p� 'I %9 i 4 f7919�'�JP��, i I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Map Page 1 of 1 Town of Barnstable Geographic Information System New search Home Help Parcel Viewer Custom Map Abutters Map Size ® ® Zoom OutaM DD to 01 flIn .F (� R Ry Q (nlfl JPG Turn map layers on/off by _ aN � �., h n check boxes I selecting below � i } X 65 .� Town Boundaries i j )S.$3 j az Road Names. ✓'/ :�. �' t i '' � ,� I_] Voter Precincts J . 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'.,.,. �� J,si �%O� � � ICKEI: ,. ,`�1 �'`L .. � .� .. .>. ::✓�. �;.t � I i I 2 THE COMMONWEAL-1"-k OF vIASSACHUSETTS .BOARD.2F H 1L...-.'H OF.............. :......-.... _ /'7U� "7 Applirttiion fur Dig oBaj Works (nourtrurtion �� .erani# Application is hereby made fora Permit to Construct (1� or Repair ( ) an diddual ew g Dispo System at: Addres •-_ ____........__..__...__.._..__.. .. ,r � Q. .. —or Lot No. _ - _— . - - O Address....................... —.--- - c = - Type of Building Address Size Lot -g�-.Sq. feet Dwelling No o = . f Be droo .................... on Attic Garbage Grinder ( Y) Expansi ( ) a Other—Type of Building ---------- No. of persons...__.._...._.._------.... Showers (I ) — Cafeteria ( ) d Other fi res - w...-..._-- ----•----- -••- - --------- --- --Design Flow..____..5 --------------------------_gallons per per son pey Total da il flo - _b - - - dons. W 0: Septic Tank I Liquid capacity.11Q':_�.,gallons Length_.._....... ----•--Width................Diameter------..........DePm------......•-- Disposal Trench—No--------------------Width_f_...- --Total Len _ - Sti?------'---t•-------Total leaching area-------------------- ft. ' 3 Seepage Pit No.......Y............. Diameter..(Q............ Depth below inle __lP __. otal leaching areaaA.4(-_ z Other Distribution box.(/`) Dosing to f9C- sq.ft. aPercolation Test Results Performed by .- C-•----..... H Test Pit No. 1.....4 .minutes per inch Depth of Test Pit____________________ Depth to ground water.... w Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.........----- x J-- __._._..._ p x Description - ------- ption of Soil —_' •--- illit?1.2��l•to y -`9 _.� •-----•--------------•----•-••--•---------••---•---..._--......----------------•---•- U Nature of Repairs or Alterations—Answer when applicable............................ ..........•--------------•-----•------------- greement 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 board of health. Sign - Application Approved By...../%� ` � Date Application Disapproved for the following reasons:.................... Date. ••-----•-----•---•-------•--------------------- ...........................................- -------- ------ Permit No Date ... - ......... -_ Issued �._7 Date THE COMMONWEALTH OF MASSACHUSETTS - BOARD O HEALTH , .....:oF..... ... ..... (9rr�tifirttt of Tnutplittttrr T IS TO CERTIF. That KeAndividual Sewage Disposal System constructed ( �r Repaired by > ) rt- ` --•-- ---•- •-----•---•• - ---••----�-• -- ljy �.f'i-'i--- Wance �stall .has been m ---- m actorh the provisions of1�I1 T r t P ��`,' j of The Sta"to S it Code as described in the application for Disposal Works Construction Permit No._:...{ _-_� - dated ,. '' THE ISSUANCE OF'THIS CERTIFICATE SHALL, NOT BE CONSTRUED AS A_GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............ �%' Inspector_.... !!_._.� THE COMMONWEALTH OF MASSACH,USETTS BOARD OF HEALTH N ................ ................................ . .. FEE.._ -- �i,s�o��jork� �o tr n rrt�tii Permission!/ X�•s rreb _ anted-._ -Y _ _ - . yh2�fYy' - to Constr ( Rip r. ( ) a /n r6ldual Se oe FS'sal em i --fSer .ht� ---�•-+--c - ............. \ C as shown on the appiicati n for Disposal Works Construction Pe it No t d J---- � / 7 IIoan o�H tth DATE------.- ll !/ 7 FORM 1255 H0138S Z, WARREN. INC.. PUBLISHERS 0 ✓ t z .� G t�l. 3r5o oil > � d Sou o � _ �. :' t( 40,ci . �`, O r ,pit., :� a . �,��".�.'� � •� TER 01 zr rm��, Askl "'a• 'L• . 51 y ,?"'z I 15 I 'z "+,i fie.. + i ba, v �40v .. ;OT r 1 r� •; s. {-,:-•s � � !• Jai .. 8., - - S•i C" Lf7 t'Ro0ri1? ,t 41. 71, wal " � � V:.✓'*+.y�9:'Ar iS,t��ANY�:,. 4 � t Y��Yt `h �� 1:::�� C� 'f �,'�L:;'X^'2 'lY l�.. � �. a. *: '- 9'.'?mil� '�."a-0 �rT'.�`�'!'�k�(lm. ,'•t' M!"a jg'�"+-� vY'a,..�., �'��::� +.a " r, , o OD TOWN OF BARNSTABLE i LOCATION EWAGE# VILLAGE C U ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 1 ize NO.OF BEDROOMS "N OWNER PERMIT DATE: \ MPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Tabl e Bottom of Leaching Facility Feet Private.Water Supply,Well and Leacli'fi 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 leach✓ng facility) Feet FURNISHED BY ' T COMMONWEALTH OF MASSACHUSETTS A EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d t DEPARTMENT OF ENVIRONMENTAL PROTECTION s+° MAP ?\ A PARCEL, CIT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 49 Buckingham Way Cotuit MA 02635 Owner's Name: Francis Griffin Owner's Address: Same - � RECEIVED Date of Inspection: August 12,2004 Name of Inspector: PATRICK M.O'CONNELL AUG 2 7 2004 Company Name: SEPTIC INSPECTION SERVICES OfOWN OF BARNSTAB'LE Mailing Address: 189 CAMMETT ROAD HEALTH DEPT, MARSTONS MILLS MA 02648 Telephone Number: 508-428-1.779 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 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 D`Ft�11111f1j approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ��ZH OF _XX_Passes 9Cti% Conditionally Passes A ••: Needs Further Evaluation by the Local Approving Authority = ;rn i Fails NNEL :Z Inspector's Signature: — Date: 8/12/2004 �'�i�� • �,�G�OQ \� -Z INSPE`�� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Observed 20-24"effective leaching in pit with a high stain 3" above current level. Recommend removing garbage grinder. ****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 ] ,Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is 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: Titles C Tnen-ntinn P^r </i,;iinnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 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. _ 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 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. 3. Other: Titla C Tnenontinn Fnrm 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool —X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP 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 forma _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility 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 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. TitbP G Tnenartinn Rnrm 6i1 4;1100n 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period ? _ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X_ _ 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 _X_ Existing information. For example, a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Titla C Incnartinn R^r 4/1 Ci7nnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 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): 3 Number of current residents:2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [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)): 2002—100,000 gal.2003—105,000 gal.=280 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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: Tank pumped day after inspection. Source of information: Homeowner 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: 21 years Were sewage odors detected when arriving at the site(yes or no): No Titla i Tnonantinn Rnrm 4ii s»nnn 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: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 BUILDING SEWER: XX (locate on site plan) Depth below grade: I' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 4" Material of construction:_X_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: 8.5' long x 5.2'wide— 1000 gal. Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tees intact and clear,tank scheduled to be Dumped day after inspection GREASE TRAP: No (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 recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Titla C incnartinn Anrm 411 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 TIGHT or HOLDING TANK: No (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: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (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.): Box set level,liquid at bottom of single outlet pine No high stains or solids present PUMP CHAMBER: No (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.): I Titles C fncncntinn Rnrm 411 cnnnn 8 • Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit 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.): Liquid level in nit 20-24" below inlet pipe with a hieh stain 3"above current level CESSPOOLS: No (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: No (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.): TWA S 9 • Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 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. Buckingham Way r�15 �0-f. 1000 gal tank 1000 gal pit Measurements taken from shed corner due to large trees and bushes between system and garage corner. If shed is moved system should be marked out for future reference prior to moving shed. Title 10 Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Buckingham Way,Cotuit Owner: Francis Griffin Date of Inspection: August 12,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 15 and topo map shows property above el.50. I Tifla C Tncnorfinn Rnrm�ii�i�nnn 11 6 HURLEY SERVICES, INC. Pumping ` Installation&Repair Backhoe Service j Title V Certification Joe Hurley&Sean Hurley° P.O.Box534 --- N.Easton,MA 02356356 508-238-2886 SUBSURFACE SEWAGE DISPOSAL SYSTEX. INSPECTION ,F o Address of property y4 BvcxinJGhS�n� wAy, GoTviT . \ owner's name .To1�i10 .�fbGrylG ' Date of Inspection lS- �!/husT !Q'SS' 'ob 10it�e� B e? 6 ��, F CHECKLIST , 4 Sys 4c Checkthe following have been done: i f h g L--'- Pumping information was requested of the owner, occupant, a Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. AA As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage' back--up. r/ The site was inspected for signs of breakout.. v All system components, excluding the SAS, have been located on the site. +s The septic tank manholes were uncovered, - opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. L__� The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. - The facility owner (and occupants, if different -from owner) were provided with. information on the proper maintenance of .SSDS.* 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 1 SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms 3 number of current residents YES garbage grinder, yes or no' YE8 laundry connected to system, yes or no lvd seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: ©ecuPi£!� Last date of occupancy GENERAL INFORMATION Pumping records and source of information: a �'✓ S S S • S 140V . A/O System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system � Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privyh Shared system jyes or no) (if yes, attach previous inspection records, if any) ' Other (explain) t, Aprproximate age of all components. Date installed, if known. Source of information: SgZn<�, -S ys7Z-,w /S o IVP Sewage odors detected when arriving at the site, yes or no 'r r 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: YK (locate on site plan) depth below grade•_ material of construction: concrete metal FRP other(explain) dimensions: sludge depth distance from top of sludge to bottom of outlet tee or baffle 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 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, recommendations for repairs, etc. ) lluLET ar✓z> O Ui -FT TZ--t"S I-12L' l�0 y2E7� /N � c.� T7/ � C O c�TL&T' 11V 1/&i�T- /1/0 .sle.a13 D,4 IzV 02 ou-r bF 7,q-,_VK DISTRIBUTION BOX: (locate on site plan) a depth of liquid level above outlet invert Comments: .(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) 7�/S�/F3 U770Yt 60X fs GEVt - NO 0! �ac,�.� er4rt�2yoT/ 1�✓ /ST/L/l3vT7l� j�o>Z_ AJ0 S/G/v.s 0, DV7 PUMP CHAMBER: N/�• f !� (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, • recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : 7f8 (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 and number _ leaching chambers and number _ leaching galleries and number leaching trenches, number, length / 3 0' X Z' leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) -sole- /S ?>2y 4'C-ji?}1 iv I�onli� ii.1G . CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, ' condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions !I depth of solids Yi Comments: 1 (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,• recommendations for maintenance or repairs,etc. ) 31 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' A g Toed Gw2• • s'��nc r►�.vK D/sr�r/e unto/�J GaH/NG i7GE7vGNPP2p 30 f �7 2 o29 �dr yS `3 " 3 g 1& / DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: 1.7,11G 5"e USA 1-3 '449G6- _ No w'q-77 P EwC4 20-2> 109-7' /D 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis -of determination in all instances. If "not determined", explain why not) �o Backup of sewage into facility? NO Discharge or ponding of effluent to the surface. of the ground or surface waters? No Static liquid level in the distribution box above outlet invert? /1/0 Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? �Q Required pumping 4 times or more in the last year? number of times pumped N® Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank• failure imminent? Is •any portion of the SAS, cesspool or privy: No below the high groundwater elevation? /V0 within 50 feet of a surface water? IVO within 100 feet of a surface water supply or tributary to a surface water supply? NO within a Zone I of a public well? AaV within 50 feet of a bordering vegetated wetland or salt marsh- (cesspools and privies only, not the SAS) ? 0 within 50 feet of a private water supply well? NO less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analy for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. r 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Joseph M. Hurley Company Name Hurley's Cesspool Service Company Address P.O. BOX 534 N. Easton, MA 02356 Certification Statement I• certify that I have personally inspected the sewage disposal' system at this address and that the information reported is* true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maiitenance of on-site sewage disposal systems. . Check one: c/ I have not found any information which indicates that the system fails . to adequately protect public health. or the environment. as defined in 310 CMR 15. 303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the- environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority LOCATION SEPIA E PERMIT NO. VILLAGE Co 7 4 Ji g /Yg--s A IKl I N S T A LLER'S NAME & ADDRESS C- _A r S 7-. W F /3 t-Is 0 U I l D E R OR OWNER o /ram I✓ DATE PERMIT ISSUED DATE COMPLIANCE ISSUED—�_ � i y� � �� - i . r , . �� _ ,- .� , THE COMMONWEALTH OF MASSACHUSETTS BOARD HE L H �...............0 F.......... Appliratiun fdur '�i-4puunl 3Uurks Tonstrnriiun amit Application is herebyfor"a Permit to Construct (X� or Repair ( ) an&diLy6ualew g DispoS stem at* OL .._. _ .. - - --- --. .__.... c ti -.-Addres .'.--•----'__--•--------------or.Lot No. . . �--�. . ... ._._.... ------------- ----------- O r ............•..........••••-•--•---...Address Instal er Address d Type of Building Size Lot..R.4.-d.-_4J—..Sq. f��fft UDwelling`—No. of Bedroo ---- ..............................._....Expansion Attic ( ) Garbage Grinder (719) p, Other—Type of Building 4„S- .-•__• No. of persons............................ Showers Cafeteria ( ) P4Other fi res -•.........................••-.............. +� W Design Flow......__ ..............................gallons per person per day. Total daily flow-_._-_-..?�.__..........__...._..gallons. WSeptic Tank j Liquid capacity.400jallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width ....... Total Length............. Total leaching area....................sq. ft. Seepage Pit No.......t............ Diameter... ..__.___..._ Depth below inle _.t9.... . .. otal leaching areaA.W#.....sq. ft. Z Other Distribution box (je Dosing to �� p Percolation Test Results Performed by...... 4�•-• 4� ..... .__ Date._-17/_r__..__ 14 ,4 Test Pit No. 1.... s2...minutes per inch Depth of Test Pit____________________ Depth to ground water-----------,............ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ t.--- . �' � ....... .. O Description of Soil ...... •--••..--- .. !a� -............... x w ••••-•-------------------•---------------------••---•-•--•-•-••-----•...........................:..................................................................................................... VNature of Repairs or Alterations—Answer when applicable_-_-__•_____________________________•--_....................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAI:'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. Sign . ... . - ... --------------------- _ Date -------- Application Approved B •. - rf............. PP PP Y �J �s Date Application Disapproved for the following reasons:-------•-------------------------------•.................................................................... -•---...--•......................•---.........-----•---------------------..............-•--•--------•------••••••--••-••••••-•--•••-•---••-•----••-•-••••----•-......---------.............-----••---- � Date Permit No.......................................... • . Issued-----tJ�' �- ........._...... Date NoFzcs '' .�.� ....� THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE ., L H ..............OF.... Appliration for Elisp u al Works Tnnitrurtiun rruti# Application is hereby made for a Permit to Construct X) or Repair ( ) an div'dual ew g Dispos System at• 4 .........._ ................ ... I - I cp n�Address ---..•...Lot ... W O r Address Y'4..... i ..................................................... ................................ ...---••.... Installer Address Type of Building Size Lot__�34__d'_..? __Sq. f t U Dwelling'No. of Bedroo's.�,�._�,*�_ ____________________________________Expansion Attic ( ) Garbage Grinder ( p) Other—Type of Building 1C!.qS_.y_______________ No. of persons............................ Showers (4 ) — Cafeteria ( ) Q' Other, fixAures ._........-•-------------•-•--.... -------•----......-- W Design Flow________ ............................gallons per person per day: Total daily flow_...__ .__gallons. WSeptic Tank--Liquid"capacitylgallons Length_____ _________ Width._.__..________. Diameter...._ . .:Depth - x Disposal Trench No_.................... Width.__.....________._ Total Length _.____ Total leaching area... ..sq- ft. " Seepage Pit No.____:t__..__.__.__ Diameter:�_0...:..__.__. Depth below i le .__ otal leaching area _.:sq. ft. Z Other Distribution box (f y) Dosing to ' t. '-' Percolation Test Results Performed by __ Ab'!t ::______'' Date.'/ %�" .7A_........_.. •- Test Pit No. i_._. Xl_minutes per inch Depth of Test Pit____________________ Depth to ground water......................... L>:, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R'+x •-•• •--.. Description of Soil........... _____ ....... __________________ W ..............••••------- UNature of Repairs or Alterations—Answer when applicable,.............................................................................................. -- ---- ------------------------------------------------------•--•--•--•--......-•---•....---...••--- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT...: 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. Sign _._. ..-•••-.._.... Date Application Approved By--- s------------------ �1 --..71"----------- t Application Disapproved for the following reasons----------------------------••---------•----------------------•----------------•------------------------•.....-- ........................................................-_............................................................................................................................................... Date PermitNo.......................................................... Issued_.... 7- ..................... Date -'t THE COMMONWEALTH OF MASSACHUSETTS BOARD Ofj HEALT .... ......OF............ :.:. .. (Irdifiratr of Tlimpliunrr T IS TO CERTIF Oance That ;Individual Sewage Disposal System constructed ( or Repaired ( ) .. - ;nstall a has been installed in accwith the provisions of 1 5 of The State S". nary Code;as described in the application for Disposal Works Construction Permit No.. ::___ _ ----------- dated_.... :._ .`__ THE ISSUANCE 00'`11-11S CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. C?�y DATE.............. �.y 7.....�.�C::..... Inspector..........................................._.....---•-------•--•-•--•-------------- THE COMMONWEALTH OF MASSACHUSETTS S BOARD OF HEALTH17Af , ......._..••--------------------------- N *"f! ..........OF._.:. .... E+ , ,'"+ K.. FEE... , """ . .�.�... .......... Raps nrku To #r frrutit s Permission s reby granted ,, , --- ... 1. -- - .......................................... to Con ( R p r ( ) a n Idual Serge sal em ,V at No.. ta Stre as shown on the applicati n for Disposal Works Construction Pe it No ___ ..1. __y:_ d.j""".__'. .!'_._`,�'_•' +� N If�f Boar o Healthy f ��*;:: DATE._`7 ................................................. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - • - - �7 a ' :' ,,y ' �`. TY. ,s�t * r� ,,. ..i y ��•, `+ J 'v 1 � 7 M ' • s .e, r , ` Y ,t( �r ,. •.EY •x !+ �y `h ._fix' r .', -1 . . R t I yt 4� ,�. .R'+•T� .1k.i�.� / 4"{ _•f !'f l. ar .�" - ♦, �'• a �'• - ...s Rq + s � t i i �!}ar „�, �' ct'}t r �`, t t 's. , ,._ �. �,.' }' ._ # • � + 4� 4,r �.-� r :jam{ + dY,d�fi �,7 � �,��G�� * _ R, ; �,,'__ .r•. . . l � _r. . � 'a i .>fi� UrJ'` ��*s A�,,„ ti�..,'4. P ff � �,. r }'� - �OI o�, ii ,.{ ,t d -t e� ` fytf ,�dy. 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