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HomeMy WebLinkAbout0061 CAP'N ISIAH'S ROAD - Health 61 CAP'N=ISI" ST COTUIT L� A = 038 070 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 3 DEPARTMENT OF ENVIRONMENTAL PROTECTION 38-0'70 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 61 Captain Isiahs Road ---��-- Cotuit. MA 02635 C'O P�/� TS Owner's Name: Charlie&Deborah Snow 1L Owner's Address: CU-"u.9�['i Date of Inspection: June 8,200 Name of Inspector: (Please Print) Jaines M. Ford Company Name: James M. Ford .Mailing Address: P.O.Box`49 Osterville,MA 02655-0049. Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have.personallyinspected the sewage.disposal system at this address and that the infonnation reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based ommy 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 .. o Conditionally Passes Nee Further Evaluation by the Local Approving Autll ority � i Fai s o E7 - w � Inspector's Signature: Date: June 10 200 CD The system inspector shall submi 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 Continents ****This report only describes conditions at the time of inspection and under the conditions of use at that . time. This inspection does not address how the system will perform in the future under the same or different . conditions of use. Title 5 Inspection Form 6/15/2000 page 1 )0)w Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Captain Isiahs Road Cotuit, MA Owner: Charlie&Deborah Snow Date of Inspection: June 8, 2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 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 detennined(Y,N,ND)in the for the following statements. If"not determined",please explain. a. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the. existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: , .. 2 . Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Certain Isiahs Road. - Cotuit. MA Owner: Charlie&Deborah Snow Date of Inspection: June 8. 2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to 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 aseptic 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 atmmonia 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Captain Isiahs Road Cotuit, MA Ow ner: Charlie.&Deborah Snow Date of Inspection: June 8.:2007 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in.the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ .Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ✓ .Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ ✓ Any portion,of the SAS,cesspool.or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to.or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No .(Yes/No)The system fails. I have detennined 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 detennine what will be necessary to correct the failure. " E. Large System:. 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. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 61 Captain Isiahs Road . Cotuit. MA Owner: Charlie&Deborah Snow Date of Inspection: June 8 2007 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 61 Captain Isiahs Road Cotuit. MA Owner: Charlie&Deborah Snow Date of Inspection: June 8. 2007 FLOW CONDITIONS RESIDENTIAL 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 gqd Number of current residents: 6 Does residence have a garbage grinder(yes or.no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL 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 Source of information: Owner was izoingto pump the system after the inspection 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: A new leach field was installed on 6128101 -per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Captain lsiahs Road Cotuit, MA Owner: Charlie&Deborah Snow Date of Inspection: June 8, 2007 BUILDING SEWER(locate on site plan) . Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: ✓ _(locate.on site plan) Depth below grade: 6" Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 12" Distance from top of scum to top of outlet tee or baffle: S" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions detennined: Measuring stick 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 septic tank was under a brick patio Cement tees were present The liquid level was even with the outlet invert. There did not appear to be any signs oMilure GREASE TRAP: None (locate on site.plan) Depth below grade: Material of construction: _concrete _metal fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 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: 61 Captain Isiahs Road: Cotuit, MA Owner: Charlie&Deborah Snow Date of Inspection: June 8, 2007 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass ._polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: .Comments(condition of alarm and float switches,etc.): . DISTRIBUTION BOX: V (if present'must be opened)(locate on site plan) Depth of liquid level above outlet invert: -- Cominents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. AMBER: None locate on site plan) .PUMP CH ( p ) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of,pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Captain Isiahs Road Comit, MA Owner: Charlie&Deborah Snow Date of Inspection: June 8, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3-500 gal. di-wells(2'x 36'x 139 leaching galleries,number: leaching trenches,number,:length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Continents (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): The drywells were haLfull. A video cmnera was used for the inspection. There did not appear to be any signs of allure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 r Page 10 of 11 OFFICIAL INSPECTION FORM -NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Captain Is.iahs Road Cotuit, MA Owner: Charlie&Deborah Snow Date of Inspection: June 8. 2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at.least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet: Locate where public water supply enters the building. A Q i �A(,k 0 � a f jig � 3 - C�- as p 3 aS 30 Y 10 V Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Certain Isiahs Road Cotuit, MA Owner: Charlie&Deborah Snow Date of Inspection: June 8,2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +1- 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: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours snaps the snaps were showing approximately 30'+k to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future., There have been no warranties or guarantees,,either expressed,written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 y -\ COMMONWEALTH OF MASSACHUSETTS ✓361 b1l) EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 61 Capn I s i ah s Rd. Cotuit Owner's Name: Earle Rettig Owner's Address: Date of Inspection: Name of Inspector: (please print) Wi 1 1 i am E. Rob nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5 0 8) 7 7 5-8 7 7 6 ' 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 DEP approved system inspector pursuant to Sec ion 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: G'v Y U ✓�l Date: tl,—c;Z 8 J The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:61 Capn Isiahs Rd. o ui Owner: Rettig Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m 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: ✓ �J S & S B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repa ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent_System will pass inspection if the exist g tank is replaced with a complying septic tank as approved by the Board of Health. •A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indi ating that the tank is less than 20 years old is available. N explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or ob tructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with an roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will p s inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed N in: . Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 61 Capn I s i ah s Rd. o ui Owner: Rettig " Date of Inspection: T 6 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 f 'ling 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. stem will fail unless the Board of Health and Public Water Supplier,if any)determines that the y ( PP Y syst m 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. r 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: x 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 61 Capn Isiahs Rd. Cotuit Owner: Rettig Date of Inspection: / —,2.Sf— 8 D System Failure Criteria applicable to all systems:. 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 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (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. arge Systems: To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd- You ust indicate either"yes"or"no"to each of the following: (The ]lowing criteria apply to large systems in addition to the criteria above) yes o the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinldng 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 ave answered"yes"to any question in Sw;nn E the system is considered a significant threat,or answered "yes" Section D above the large system has failed.The owner or operator of any Inge system considered a signifi ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.30 .The system owner should contact the appropriate regional office of the Department. 4 Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 61 Caan Isiahs Rd. Cotuit Owner: Rettig Date of Inspection: Check if the following have been done You must indicate"yes"or"no"as-to each of the following: Yes o 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) V Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _.u/_ Existing information.For example,a plan at the Board of Health. J _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15302(3)(b)] 5 Page 6ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 61 Capn I s iahs Rd. Cotuit Owner: Rettic Date of Inspection: r—© j FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual)' DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 'Z Number of current residents: -9L-1 Does residence have a garbage grinder(yes or no): /tea Is laundry on a separate sewage system(yes or no):�Le) [if yes separate inspection required] Laundry system inspected(yes or no):/I.., o Seasonal use: (yes or no): A-1v Water meter readings,if available(last 2 years usage(gpd)):2()o 73 , 000 gal. Sump pump(yes or no): A-d 1999 108, 000 gal. Last date of occupancy: C MMERCIAL/INDUSTRIAL Typ of establishment: Des! n flow(based on 310 CMR 15.203): gpd Basis f design flow(seats/persons/sgft,etc.): Greas trap present(yes or no):_ Indus ial waste holding tank present(yes or no):_ Non-s itary waste discharged to the Title 5 system(yes or no):_ Wate meter readings,if available: Last ate of occupancy/use: OT ER(describe): GENERAL INFORMATION Pumping Records Source of information: '�li Was system pumped as part of the inspection(yes or no): If yes,volume pumped:Zj2c�D allons-- ow was quantity pumped determined? J ye U Reason for pumping: a ��1l d .a TYPE F SYSTEM eptic 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: t om` A:g-d T-O C Were sewage odors detected when arriving at the site(yes or no): A-6 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Capri Isiahs Rd. Cotuit G Owner: Rettig Date of Inspection: BUI ING SEWER(locate on site plan)' Depth b low grade: Material of construction:_cast iron 40 PVC_other(explain): Distanc from private water supply well or suction line: Comme is(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: /(locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: 0 —I i Distance from top of gludge to bottom of outlet tee or baffle:of `"J Scum thickness: CJ 1 Distance from top of scum to top of outlet tee or baffle: ti Distance from bottom of scum to bottom of outlet tee or baffle: l?� How were dimensions determined: 0 -&±f '1'� '4' 1e Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): S GR SE TRAP:_(locate on site plan) Depth b ow grade: Material construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensio s: Scum thic ess: Distance om top of scum to top of outlet tee or baffle: Distanc from bottom of scum to bottom of outlet tee or baffle: Date o last pumping: Co nts(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as relat d to outlet invert,evidence of leakage,etc.): 7 Page 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Capri Isiahs Rd. o uit Owner: Date of Inspection: — "O TI HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth elow grade: Materi 1 of construction: concrete metal fiberglass_polyethylene other(explain): Dimens ons: Capaci gallons Design low: gallons/day Alarm resent(yes or no): Alarm evel: Alarm in working order(yes or no): Date f last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: v(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Ly PUM CHAMBER: (locate on site plan) Pump in working order(yes or no): Al in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 {? Page 9 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 CaAn I s i ahs Rd. Cotuit Owner: Rettig Date of Inspection: & Z—d SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type aching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.): ,Q -d 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:r ' Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failurejevel of ponding,condition of vegetation,etc.): PR (locate on site plan) Mate ials of construction: Dime sions: Dept of solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 ` Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Capn I s i ah s Rd. Cotuit Owner: Rettig Date of Inspection: 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. 3 ` D o v� 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Capn Isiahs Rd. o ui Owner: Rettig Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_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: served site(abutting property/observation holeWithin 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: x 11 No. FJ 5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for �Dioogaf *pgtem Congtructi.on Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Asses61so,CsMp7Par eip Isiahs Rd. , Cotuit Earl Rettig Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. 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 Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system con— sisting of a D-box and 3 precast leach chambers with stone all around. 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 f He . Signed e '�� Date " S o Application Approved by - Da Application Disapproved for the following reasons Permit No. Date Issued -». F$5 0 No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: n PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes 01pprication for Mioogal *pmem Congtructfon Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address orLot No. Owner's Name,Address and Tel.No. Asses 6sor�'sap7Prar ein Isiahs Rd. , Cotuit Earl Rettig _ —7 Installer's Name,Address,and Tel.No. i Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. 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 Size of Septic Tank Type of S.A.S. Description of Soil Sand � I Nature of Repairs or Alterations(Answer when applicable) Title'=5x leach system ,cone sisting of a D-box and. 31precast leach ahWnbers`twith stone all around. f 4F i Date last inspected: i J ' % ; ~ Agreement: The undersigned agrees to ensure the construction an'd 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 beenVissued by this Board f He h G Signed, �--� Date t Application Approved by / Da c .. Application Disapproved for the following reasons Permit No. Date Issued s THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Rettig Certificate of Comphance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service r at 61 Captain Isiahs Rd. , Cotuit has been constructed'iirraccordance with the provisions of Title 5 and the for Disposal System Construction Permit No.7.00 f—3-�dated /0/ ZOVf InstallerWm. E. Robinson Sr. Designer The issuance of this permits ll not be construed as a guarantee that the sys fu tion desigQ2222 , Date Inspector ---------------------------------------- — No. 1_ W ` J�"U - _ Fee$5 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS @ tig lwf 6ponf *pztem CongtructtottPerm.it:/" Permission is hereby anted to Construct( )Repair(X )Upgrade(1 1)Abbnon�`'( System located at A Captain Isiahs Rd. , Cotuit 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. k, Provided:Con tru Clo/m�t be completed within three years of the date of this permit. Date: _ ,, Approved by tl6M ' a • NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. C1rRTtRtit�.t►TiON OF SKETCH AND APPI.ICATiON FORA DLSFOSAL WORKS CONSTRUMON PE tuff(WfC'HOUT DESIGNED PL ANS1 William E_ Robinson,5y certify Hiatt the application fir disposal works onasarmcaon pertnio<igued by we dated the property located at 61 Captain I s i ah s Rd. , Cotu i t meets all of the following criteria: • The failed system is eonoased m a vendential dwelling only. These am no commercial or business uses associaftil wish the dweft& The soil is clod as CLASS t and dw pmwafmm tale is lew than or equal to S wan un per inch Thar-are no wComtds within 100 feet of the ptttpand 9*8c kvucm r, Tlv=art no pnvalc wdls within 150&a at thr proposed scpw sys art There is w mcrease to flow=dAK chow m vw pmpmd • There we no vwimuxs iteLplGuM or needed The bonom of the pRop bcft win nic be i =fed else than five fax abwe the maamum adjmted gmandvtater table elevaum [Adp a the gmandwmer table Us- the Fnmptor Ittethod when Vie( If the S-A.S.will be located YPA 250 fct of aW veg rated wedands.the banom of the proposed teaching facility wilt nM be%cad k=than fatnteen(14)fact above the aaamum adjusted gratn(Water able elevation Please comphse the tolluwiW A) Tots of Grand Stubm Ek wades(lt�g Gis kaumvi n) GP B I G.W.Ekwadon +the MAX.Wvh G.W.,Vdjmzment = �' DIFFERENCE EEI VUEEN A and 0 J r SIGNM: DATE: [ pr+nposod plan of system an bade. •r newt :�� G s �. �� �---- � � p � 1--.=� -��� TOWN OF BARNSTABLE LC,���;. TIOh; L I` CA ID iAl YJ ;LsiA h S BOAD _ SEWAGE # VILLAGE CCA-Ur 4' ASSESSOR'S MAP & LOT b 3 70 { INSTALLER'S NAME'&PHONE NO. ' SC--jQC C 7 7 S"27-3 SEPTIC TANK CAPACITY 1 6 0O LEACfIING FACILITY: (type) 3 ' "U X S' (size) ;tY 3L )(1.3 NO. OF BEDROOMS 'f BUILDER OWNS PERMIT DATE: 6' r-0 C OMPLIANCE DATE: I Id aD b Separation Distance Between the: Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist, withi.n 300 feet of leaching facility) Feet µFurnished by _ n 4� Q w asY e tom. n o fi� h TOWN F BARNSTABLE I6t:ATION SEWAGE# VILLAGE =-, ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY I LEACHING FACILITY-(type) (size) aX 3Gx 13 NO.OF BEDROOMS 4/ OWNER Sn0W PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ) Feet FURNISHED BY'-/1S�0tj On 1 0� q a 9A(,k O 3 a- /( 0-1a p 3 as 30 y 3� YO