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Home My WebLink About0140 CAP'N SAMADRUS ROAD - Health P.oa� 140 CAP-A/ SAMADRUS (COTUIT) i J L O CA-7 ON SEWAGE PERMIT NO: VILLAGE -`-- �d l U INSTALLER'S NAME & ADDRESS f�- CA ca v S' e U I L D E R OR OWNER- DATE PERMIT ISSUED DATE COMPLIANCE ISSUED / �� 'fir .. � Q Yl� ,' __ i `� a 1 * S i - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M . 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner' Name information is required for every Cotul -Barnstable Ma D page. Cityrrown Code Date of of i State Zip 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 � a q on the computer, / use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway key the return Name of Inspector Y (► � H.P.S. �I Company Name P.O.Box 151 �I Company Address Forestdale Ma 02644 Cityrrown State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/12/17 Inspector's Signat Date The system inspector shall submi copy of this i pection report to the Approving Authority(Board of Health or DEP)within 30 da of completing,t is inspection. If the system is a shared system or has a design flow of 10,000 d or grea the inspector and the system owner shall submit the report to the appropriate regi Ice of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. J ****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•3113 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 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is Cotuit-Barnstable Ma required for every 3/12/17 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 d any information which indicate s 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: Septic in working order. Existing septic system is H10 rated. Automobiles and heavy equipment should not be driven over septic area. Pump tank every 2-3 years to avoid backup and premature leaching failure. Instructions and proper care info for septic systems can be found at town hall health Dept or online. 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 complyingse tic re laced with atank P p as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachu setts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is every Cotuit-Barnstable required for eve Ma 3/12/17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y - ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Forth: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 Y 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owners Name information is required for every Cotuit- Barnstable Ma 3/12/17 page. City/Town State Zip Code Date of inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit-Barnstable Ma 3/12/17 page. Cityrrown 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. E] ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurfac e Sewage Disposal System Form-N 9 P Y of for VoluntaryAssessments is G M 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owners Name information is required for every Cotuit- Barnstable Ma 3/12/17 page. Clty/rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following:. Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 140 CaP'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit- Barnstable Ma 3/12/17 page. City/-rown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage gander? El Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit-Barnstable Ma 3/12/17 page. Cityrrown 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: realtor pumped 2 months ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y � 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit-Barnstable Ma 3/12/17 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: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+ ' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: less then 1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit-Barnstable Ma 3/12/17 page. Citylrown 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 34 11 Scum thickness less then 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 20" How were dimensions determined? tape and sludge judge Comments(on pumping recommendations,'inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump every 2-3 years as maint. to protect leaching 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•3/13 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 V.y�. 140 Capin Samadrus Property Address Lisa Cooper Owner Owners Name information is Cotuit- Barnstable required for every Ma 3/12/17 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.): baffles in place. no visable cracks or leaks Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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•3/13 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is Cotuit-Barnstable required for every Ma 3/12/17 page. Citylrown 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.): Dbox has no visable cracks or leaks. water level is at bottom of outlet pipe and no staining higher then current level to indicate past failure. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: inspected through Dbox. no inspection port on leaching proped stone area around chambers no hydraulic failure found t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts 'Poll' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ( 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit-Barnstable Ma 3/12/17 page. Cttyfrown State Zip Code Date of inspection D. System Information (cunt.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1)1 1'x30'x2'3 maximizers ❑ 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.): 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit-Barnstable Ma 3/12/17 page. Citylrown State Zip Code Date of Inspection D. System Information (coot.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is Cotuit-Barnstable required for every Ma 3/12/17 page. Citylrown 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 Jam` V b a 3 - a t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owners Name information is Cotuit-Barnstable required for every Ma 3/12/17 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: 50+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: town GIS maping lot el. 60 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 TWe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 140 Cap'n Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit- Barnstable Ma 3/12/17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r F Commonwealth :of Massachusetts Title. 5 Official Inspec ion Form 0 Subsurface Sewage Disposal System Form .- Not for Voluntary Assessments M 't 140 Captain Samadrus Property Address: .... Lisa Cooper ..Owner: Owner's Name information is required for every Cotuit MA 02635 12/31/12 page:" City/Town State - Zip Code,: Date of Inspection - Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information - on the computer,use only the tab . _. . key to move your 1 Inspector: cursor-do not Ricky Wright use the return key. Name of Inspector B & B Excavation,lnc. �p Company Name .14 Teaberry Lane. .. Company Address Forestdale MA: .02644 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License.Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and mthat 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 15000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑` Needs Further Evaluation by the Local Approving:Authority 12/31/12 Inspector's Signature Date The:system inspector shall submit.a copy of this inspection report.to the Approving Authority(Board of Health or:DEP)within 30 days of completing this inspection. If the system is a shared system or has a design.flow of 10,000 gpd or greater;the inspector and the system owner shall submit the.. report to the appropriate regional office of the DEP. The original should be sent to the system owner ...and copies sent to-the buyer,:if.applicable, and the.approving.authority..:.. This report onlyAescribes 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•11/10.:: Title 5 Official Inspe.c:io o ubsurface Sewage/irposal System__Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Captain Samadrus r Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 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): t ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 it Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a.public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 Y day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 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 Pi e s . Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts .. Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 140 Captain Samadrus Property Address: .. .... Lisa Cooper Owner: - Owner's Name .. information is Cotuit MA 02635 12/31/12 required for every page. City/Town'' State Zip Code Date of Inspection - C. Checklist ..:::Check if:the following have been done:.You must indicate":yes' or"no" as to each.of the following: Yes: No Pumping Information was provided by the owner, occupant, or Board of Health ❑ Z Were:any of:the:system components pumped out in the previous two weeks? Has the system received normalflows: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 El ® approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System.Information Residential.Flow Conditions: -.. Number of bedrooms(design):._ Number of bedrooms (actual);. DESIGN flow based.on 310 CMR 15.203(for example: 110 gpd x#of bedrooms)- .. 330 l5ins•11/10 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 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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 ears usage d n/a 9 ( Y 9 (gP ))� Detail 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I _ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 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: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 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: 14 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >5' Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 1000 gal Sludge depth: 6" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 14" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour 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.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. 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 l5ins•11/10 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 s 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 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 ❑ 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•11/10 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 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 page. City/Town 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 M 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.): At time of inspection d-box appears to be in good condition. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: (3) maximizers ❑ 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.): At time of inspection leaching appears to be in working condition. Water level 15 " below invert. No sign of hydraulic failure 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 page. City/Town 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 El - Z A1 =V BI B2 Z9 ' A3 = U ` �133 36,(o tf k t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit MA 02635 12/31/12 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 15ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM s 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 . page. Cityrrown 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, t use only the tab 1. Inspector: key to move your v cursor-do not Ricky L. Wright - use the return Name of Inspector key. B & B Excavation, Inc. Q Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/17/11 Inspector's Signature Date The system inspector shall submit a copy of this inspection.report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only _ p y 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•09/09 r Title 5 Official Inspection Form:SubsurfaJS. geDisposal System•Page 1 of 17 i— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 140 Captain Samadrus Property Address Lisa Cooper _ Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 page. City/Town 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: ® 1 have not found any information which indicates that any of the failure criteria described. in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be' replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. I Check the box for"yes", "no" or"not determined" (Y, N,;ND)for the following statements. If"not determined," please explain: The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally unsound,.exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health: *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 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): 4 ❑ 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): r 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. " y 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 I ❑ 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 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 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 ® 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 El ® 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 L - Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required Ma 02635 8/17/11 requiredd for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® -Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or.privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking-water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system'obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health ®- ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 MDESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 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 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 page. Cityrrown 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No -Last date of occupancy: 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 Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date r 4 Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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) El 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 r. ❑ Tight tank. Attach a copy of theDEP approval. ❑ Other(describe): r t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 5 140.Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is Cotuit Ma 02635 8/17/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: approx 20 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20'feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good condition. No sign of leakage Septic Tank (locate on site plan):, Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance. (attach a copy of certificate) ❑ Yes ❑ No I Dimensions: 57-X 5'2"X 8'6" I - Sludge depth: no sludge t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 140 Captain Samadrus Property Address ; Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 page. Citylrown 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour 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.): At time of inspection septic tank appears to be structurally sound.Concrete baffles present- no sign of leakage Grease Trap(locate on site plan): Depth below grade: feet Material of construction: - ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: y Scum thickness Distance from top of scum to top of outlet tee or:baffle MDistance 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. °wM 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 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 ❑ 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 �M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . . Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No d-box 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma . 02635 8/17/11 page. Cityrrown 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.): At time of inspection leaching appeared to be in working oder.Water level was 11" below invert, any increase in flow might change leaching conditions. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration F Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool h Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•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 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t ^ r t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma 02635 8/17/11 page. City/Town 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 C � 3 Flo 0 t5ins•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 140 Captain Samadrus Property Address Lisa Cooper Owner Owner's Name information is required for every Cotuit Ma' 02635 8/17/11 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: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•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 140 Captain Samadrus iV^M Property Address Lisa Cooper Owner Owner's Name information is Cotuit Ma 02635 8/17/11 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D,or E checked. ® Inspection Summary D (System Failure Criteria Applicable to"AII Systems) completed { ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LW,7N-TICN NO CA�- S4 M/aC!rL S SEWAGE # 5?- 1-7 S VILLAGE CO+tI+ ASSESSOR'S MAP& LOT 038 0`/s INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I OM GA� LEACHING FACILny: (type) 3 M4,<AM12e,,,S (size) 1) X 30`X 8 NO.OF BEDROOMS 3 BUILDER OR O R ✓�1Ar� Z 1 PERMITDATE: 3 a0 q COMPLIANCE DATE: V �► C) 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 facili ) � Feet Furnished by — @ •� i�_y 3 aco q - d - _ M s .9 ,19 f ` M M OD O TOWN OF BARNSTABLE •C LOCATION g SEWAGE # VILLAGE-4 ASSESSOR'S MAP & LOT 63 9, 6,4 INSTALLER'S NAME&PHONE NO. ft 60 2 7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ri�, ® "�' (size) NO.OF BEDROOMS J T BUILDER OR OWNERd �� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet r Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) l ;' Feet Furnished by - � r N.. `t Fee $50 . 00 THE COMMONWEALTH OF MASSACHU TTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Miq;paar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 4 2 8—61 4 2 140 Captain Samadrus Road Walter Lindberg Assessor's a , 4,y tuit, MA 140 Captain Samadrus Rd, Cotuit Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Sry PO Box 1089 , Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder J10) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of D—box and 3 H-20 maximizers Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved b - Date- Application Disapproved for the following reasons Permit No. Date Issued --- ------------------------------------- TOWN OF BARNSTABLE LOCATION SEWAGE# 9 T 1 ..:VILLAGE ASSESSOR'S MAP &LOT:7�$- [S�, `INSTALLER'S NAME&PHONE NO.Kd i 7 1. SEPTIC TANK CAPACITY �6��0 ► f >: LEACHING FACILrrY: (type) 3 W,�2 0 °` (size) ,:NO:OF BEDROOMS 3 "....':BUILDER OR OWNER PEiMITDATE: COMPLIANCE DATE: egatation Distance Between the: ; Maiumum Adjusted Groundwater Table and Bottom of Leaching Facility Feet ::::Private Water Supply Well and Leaching Facility (If any wells exist `on site or within 200 feet of leaching facility) Feet <:jE,dge of Wetland and Leaching Facility(If any wetlands exist <, within 300 feet of leaching facility) l Feet "`Furnished by 1~ I t -Vv(/ J 1 s offLl �j e No. 9 � / � Fee $5 0.0 0 THE COMMONWEALTH OF MASSACHU TTS Entered in computer- { `Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for �Diq ooal !tent Construction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete Sysiem ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 4 2 8—61 4 21 140 Captain Samadrus Road Walter Lindberg Asses so�'sa help twit, MA 140 Captain Samadrus Rd, Cotuit Installer'r'►s Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Sry ` PO Box 1089, Centertille, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no) Other l Typeof Building r No. of Persons Showers( ) Cafeteria( ) Other Fixtures = r 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 Leaching consisting of D-box and 3 H-20 maximizers Date last inspected: _Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved b Date 1710 Application Disapproved for the following reasons N L Pe\ t No. •' Date Issued ,- THE COMMONWEALTH OF MASSACHUSETTS ` Lindberg BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (xv)Upgraded( ) Abandoned( )by at 140 Captain Samadrus Rd, Cotuit ha een constructed in accords ce with the provisions of Title 5 and the for Disposal System Construction Permit N dated '` Installer W E Robinson Sept Sry Designer The issuance of this permit shall no be construed as a guarantee that the system-will function as designed. Date 4 Inspector No. /91� -----------------------.---Fee $50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Lindberg ioogal *pgtent Construction Permit __Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 140 Captain Samadrus Rd, Cotuit, MA Installer: W E Robinson Sept Sry and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thi �-"rmit. Date: � � Approved b (/ Li t NOTICE: This Form Is To Be Used For the repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated 6 concerning the property located at 140 Capt Samadrus Rd, Cotuit, MA meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * ASSESSORS MAP N0: There are no private wells within 150 feet of the proposed septic system. PARCEL N0: * There is no increase in flow and/or change in use proposed. * There are.no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: / �1 A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) /, l B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: y' DATE 3 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OFBARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). i { I ^ r r�J� i � � 1 w ra s.. tr w ' c_, � - �zt v k' (' ..O ` l II a Q I �♦ �� .� '. ! i ®Py v I COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE ®FFIC,E OF ENVIRONMENTAL AFF S x DEPARTMENT OF ENVIRONMENTAL PRO TIQN , \ ONE WINTER STREET. BOSTON. MA 02108 617.292-5500 4R ; 'f 1998 yFq(Ty�`j)B�F Of WILLIAM F.WELD /�I ��f S e TR XE Govemor /� „J� cretar}• ARGEO PAUL CELLUCCI A STRUTS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 11VO 6 apt Sq'JY1gta/tU,$ kw, Co uJT- Address of Owner:' Date of Inspection: ala19/919 (If different) Name of Inspector: foe M1?R r1/VS ° am a DEP approved system inspectf r pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: CCaC SP C�1 C& Mailing Address: ] Y f/ t? s' hAIS �► /� ®2((O Telephone Number: 5-0,f-- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes ' —y Needs Further Evaluation By the Local Approving Authority Y ails Inspector's Signature: Date: z IOWA?- The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: 1` One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon D completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) .years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rovined 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/Aw+w.magnet.state.ma.us/dep rL j Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)) Property Address: �e(J (�7q /'Q/n ��S�®q� �O 6lJ� Owner: Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) — Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,.settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four.times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER (reviaod 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: IVQ (."(jP/'g1..j Ssr�ip�d v3 �OpGb j d0lv/7 Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate ei;,,er "Yes" or "No" as to each of the following: 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination.is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sews a into facility or system component due to an overloaded or cl ged SAS or cesspool. •El/i0X OF 54(57; IN60 ��vp She Ce wm-e. -6 9 . L/4�urm 4�v/lam i�v �c � Y- 1 rl? ,vim �00(cr` ile ��Discharge or pon ing o e luent to a su ce of fNe gr and su c aters ue an o erloa e or c ogged SAS or / cesspool. V 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. d� Any portion of a cesspool or privy is within a Zone I of a public well. 6� Any portion of a cesspool or privy is within 50 feet of a private water supply well. _V 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System a system is a significant threat to public health and safety and the environment because one or more of the f ig conditions exist: Yes No the system is within 400 fe surface drinking water supply the system ' in 200 feet of a tributary to a surface drinking water supply _ e system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) e owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revlaod 14,11,17) Page 7 of 10 I i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ` Property Address: f`Q� Q �� Ja,4 Q411'4'5 Owner: !r7 �1 Xj Date of Inspection: /a8/9 � Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: pp Yes No l� Pumping information wi-s provided by the owner, occupant, or Board of Health.(7_regfmvni- /QP7P"J I/ None of the system components have been pumped for at least two weeks and the system has been receiving normal t flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 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. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, et, have been located on the site. ✓_ _ 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. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. .512e- //Vr—p A/.�.sG _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 1 Property Address: /L/Q p7'q�� S�m4Y,�(/,y / Oo�j/ Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom for S.A.S. I✓OT "" 6e� Number of bedrooms: Number of current residents: Garbage grinder (yes or no): r'd Laundry connected to syste (yes or no): �.5 Seasonal use (yes or no):�/O Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): ND Ve y V St �o�,t7 — o�✓�� Last date of occupancy: ��CyPlec� COMMERCIAUINDUSTRIAL• Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or Non-sanitary waste discharged to the system: (yes or no)_ Water meter readings, if av Last date of upancy: HER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING ECORDS and ource of information: / vrrr Pa 12-- /2-- -SOV r ce, System pumped as part of inspection: (yes or no)- 0 10elZ ®W,7'e&, (,?vtneV Ax If yes, volume pumped: gallons 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) I/A Technology etc. Copy of up to date contract? Other PPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) �j d (rovised 04/25/97) Page 5 of 10 I � i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (fq`OTQ/vI S�da�o-(/f ��.� �o // Y �j9 Owner. �- Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron V 40 PVC M other (explain) Distance from private water supply well or suction line AIO Diameter 6L/ Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) ,eta l.L.)v Depth below grader� ��Co�.�o7 i" � �i��"� Material of construction: I concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) C /I^Dimensions: ��/� y 6 � / Sludge depth p Distance from top of sludge to bottom of outlet tee or baffle: IAI - Scum thickness �n// 11/7 Distance from top of scum to top of outlet tee or baffle: 7 e/ Distance from bottom of scum to bottom of outlet tee or baffle: /OZI How dimensions were determined: [�a a�'� -�'J7�� Sludfe J 4,4 Comments: (recommendation for pumping, condit� of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, tructural integrity, evidence of leak ge, etc.) C / u 11 Iki t/ P �v �e — L ��s�,' � V�rG �l4 /.�/P�- eovel(. -�eee GREASE TRAP: tom?H' 'Ii r�%��—/ 400$v/® 4eVe f 00�Xe74- (locate on site plan) �4� o be P112 p� »t®be-Pe¢//, -eI17e 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 t affle: Date of last pumping: Comments: (recommendation for p ing, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evident eakage, etc.) (revised 04/25/97) Page 6 of 10 r-� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION (continued) Property Address: /yv 0q/p7-q1� S rnaa �-v5 Owner: / Date of Inspection: J TIGHT OR HOLDING TANK: (Tank must be pumped prior to or at time, of:inspection) P P P �(locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene of ain) Dimensions: Capacity: gallons Design flow: gallons/ Alarm level: in working order_Yes; _ No Date of previous pu ng: Comments: (conditi of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: F7D®Ili 0Of[,e' 14(I k 7- Comments: 7� (note if level and distribution is equal, evidence of solids carryover, evidence of leakage int or out of box, etc.) �// ,BOX EV L ' — L PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No)®_ Alarms in working order (Yes or No) Comments: (note condition of pump chamber Ilion of pumps and appurtenances, etc.) — I (revised 04/25/97) Page 7 of 10 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / / v /n Cqp/ a/ Owner: b`, Date of Inspection: �-5 �� SOIL ABSORPTION SYSTEM (SAS): " (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. l�d`Q (�� leaching pits, number: S�wL� A P• ✓ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: / leaching fields, number, dimensions: �( /�V► �°�Qt/Q overflow cesspool, number: /1 Alternative system: Name of Technology: Comments: (note condition of soil, signs of h draulic failure, level of nding, condition of vegetation, etc.) R v /( / L v ` �/ c//Gt/�t,o/ P'Ovnc .t /"�,�►oq•/�/� /n p�f Oo! ��7 ,Si�,P®� AlG� cEssPools: Off f- /i q of d /-ew/ is a6o✓e /eacA p/t (locate on site plan) sVeweir 1201as "n , ;;� 0 l N 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 (cessp ust be pumped as part of inspection) �,mems: (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 hydr c f�Ievel, ponding, condition of vegetation, etc.) (rovioed 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /7 0 f7 T—C// Owner: L r/1��j�r' Date of Inspection: ,S SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) F20nj 'r or- ftsE I I , 10,57 136 s 2\6 4 13 D D 9 F- 35� .� 39,� ' DR�u�a6 MOT 7�) SCE; (revised 04/25/97) Page 9 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 17�d� Date of Inspection: Depth to Groundwater _ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) (6rd e-e.. A0 ze'qC4®/I— �30M4 Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers jzuse USGS Data 61 S Df, Describe in your own words how you established the High Groundwater Elevation. (Must be completed) 3. �� O �Ar�1s6�� '" �D✓I7�v i 41 /71i6 # 6tvL)0-9 0C�CP_ rWO/;A Ae7-cl A17 (rovieod 04/25/97) Page 10 of 10 ' � �� . 03� -� ' - F�B'J��__--' ` ~-~ �e� COMMONWEALTH ��ss�o�us��s ' � BOAR ` ........... -....OF......... .�N.1.ZKZ.][ ......................._ ,~ _ � �m�^ �� ~ ' ��^��lir�»tiou� *«"� ��*zo�,x��xoo� ��»or��/ v�onsuruWrtion @6mitApplication � . ^�� is hereby oou� for u Permit to Construct ( �� or Repair ( \ an Individual Sewage System at: .SAM.pLapw .( Location-Address or Lot � � /=="= Address Type of Size -' - - ' '" feet Dwelling Attic Grinder �� Other—Type of Building ............................. No. of persons............................ S6mrcro ( ) -- Cafeteria ( ) ^� ~ .--_----_--_--'-__---__--._-_.-__.-_.-.---_--_----------------'--- DesiQn Flow.....��--__-____ per person per day. Total daily flow.- ____-__ � SeoticTuok--Liqoid capacitylOW..gallons Length................ Width................ Diameter---- ---.... Depth................ Disposal Trench - .................... Widbb--.�-----' TotalLength Totalleaching urc ....................uq. h. Seepage Pit No.... /----. D�ueter-'��.�...... Depth below inlet...Ir.'�.......... Total leaching area.=XPA....sq. ft. Z Other Distribution box / \ Dosing ( _ ~~ Percolation Test Results' I` ' erfocozed6y- V".. i�WI.,t1v- -------�-------' D�c-�1--��.....-`E/......... '14 Test Pit No. l---_---.noinuutesperincb Depth of Test I,iL---------' Depth tv ground water........................ Test Pb No 2................minutes per inch Depth of Test Pd.--------- Depth to croouJ water........................ ----------------------------- '....... --------------------------------------- ------- '----------- -------- ------------------------------- - ^^ Description cf Soil........................................................................................................................................................................ ---'-------`---'---------------`-`-----`-----`--------`----`-`-`--`-`----------------`--`--`------ -_-__'_._-_.-_--_'-_.-_-'--__--____.__----.'_--_-'-_-_-'----_+..__-_--_---'-'---. U Nature of Repairs orA&ocutions--Anuwcrwhco applicable--------------'_-------.-_--'----__----- ' Agreement: . The undersigned agrees to install the afo �ribed Individual Sewage Disposal System in accordance with the provisions of TL I TL U 5 of the State Sanit, ?�Mod - The n ot to place the system in operation until a Certificate of Compliance has ItQ1,1s ed by t oar li a Date � Application ^^ d for thefollowingreasons: ` Date Permit No �� Date ------- ' ��-- --_---_---- -___ No.. . z ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C7.Lt�!.. ................ ......................... ... �a'��. ,'�"- L. ApplirFa#iun for Uispuial Vorkg Tonaraurtion Frrutit Application is hereby made for a Permit to Construct (1/`) or Repair ( ) an Individual Sewage Disposal System at: ..... AEI ►. ....AMAD.R?.QA-. Z T....................................I.......-------- Location-Adds or L No. F HAM l4 9- , ........... :.�.x . �. s . . Address Lot.................................... ..................... r .... . .......................................... Owner Address W Installer Address Type of Building Size Lot............................Sq.F41) �. Dwelling—No. of Bedrooms......... .............................Expansion Attic ( } Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures ..------•-•--•------------------ . W Design Flow.....,diS................................gallons per person per day. Total daily flow-----3*?0...........................gallons. WSeptic Tank—Liquid*capacity1_ -.gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No..................... Width ...._........... Total Length...../.._.f------ Total leaching area.._................sq. ft. Seepage Pit No......./............ Diameter.__J............. Depth below inlet.._�P.._._._....... Total leaching area.��(�.......sq. ft. Z Other Distribution box ( ) Dosing t k Percolation Test Results Performed by---------- ----ik&�tM............... T 4'/ � ---------------- Date----...---- .�-------........... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ---•------------------------------••-----•------...----•-----------........---------•--••--•-----•-.......................................................... 0 Description of Soil..........................................:...........----...--•---•--------.....-----------------------------....-------------••--------•----------••......------..--•-- x U .....--•-------------•-----------------•--•-----------------------------------------•----------------••---------------•---------....---•-•--------------••••-----•-----•••--•-----------••......------•-- w ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------•••••----•------------------------------------•----•------••---•-----.....-----------.................--••--•----••-•-----•------------------•---••-----------------------------.............-••. Agreement: The undersigned agrees to install the afo ribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanit y Code The and d rther agr s not to place the system in operation until a Certificate of Compliance has & '.s ed by the oar o h - Signed.........-••..................:..... '... .... --------- .. .... . Date Application Approved BY — -/ .... ' ...... xr2�•j-- Date Application Disapproved for the following reasons:-----•-----------------•----•-------•-----------------------••---------------.....•---•-•---...-•----.........._ ..........................••-----••-.--------------...------------------......••------.......•---------....--•--••-•••-•--•••----•------••--•-•----•------•-----•-•------------------------------- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH_ ........ ..........OF......... n-% � ........................... (Irfifiratr of TuntpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed 4__�or Repaired ( ) by-------------------------------------------------------------------------------------------•----------------------------------------------------------------.--------------------------------------- In Iler at................ - ---•-�--� ...............ht t rt------•-----.. ........................................................... been installed in accordance with the provisions of TIT_LE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-- -8 ........... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHAH. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................90 1'1-1.1a4.---•-------•---......... Inspector-------------• - . ....................----•--.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. 'i�J'�,.:......O F.........:.. ..:.-:. :w!: . ......................_........ N &'�... GQ FEE........................ Disposal ur Q1un,drn #iun Vpprmit Permission is hereby granted.. to Construct '�or Re air ( ) an Individual Sew e Disposal System , at No......... !'';-- •-�---... _ ...... ---- -------- ---c.. w-1 -<r �....---------•--•---------•................•-• . Street as shown on the application for Disposal Works Construction Pe mit No..................... Dated. ....................................... Board ealth, DATE . ... --------------- FORM 1255 HOBBS & WARREN. INC...PUBLISHERS _ I 1 ' 1 ram: s ^ 1 A / ROBERC 4\•� BUMKIS !: � r ti_v o tiinn,. •i ,, Na.'L216t C�.,. � -Ctd EN D EXISTING SPOT ELEVATION Ox0 CERTIFIED PLOT PLAN EXISTING CONTOUR --- 0 -- - /-a 7-- -5 A' 14A D fL/s. FINISHED SPOT ELEVATION Q. FINISHED CONTOUR 0 G.� T-y/ 7- IN APPROVED BOARD OF HEALTH SAA1118 ta �L jld`-®A A DATE_ AGENT SCALE, / r=4o DATE=G 7+4 1/ -DREDGE ENGINEERING CO. IN Cui�T7w CLIENT I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. /v 2 BUILDING SHOWN .ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER SURVEYOR --- - OF BARNSTAB.LE, MASS. f ,p 712 MAIN ST. CH. By, *- HYANNIS, MASS. SHEET_:- OF L= ,DATE REG. LAND . SURVEYOR 7'HESEP7/C,T.4NlC OR -- A/tE /Jo RE TNA,,V•IZ"BELDyV /O FT. M/N. rRAOE� f� P4"O/AM ETE!p G'0/yG"R.�'TE CORER, SNALL BE B%QO//G.WT T'O 64AGE.64I✓ ,EJ�'Tiei9 ' CONCRETE. 4~PYC. P/PE ;�E.4Y;Y C/1 ST. ./RO/Y CO�/ER .SHALL :QE.USE:q , EGWit✓..I v o,D COIiE/�.S r M/N.:P/TGH `ZzY,00r'/Ale L>R/VEH/AY 4CID/VCR1�TE A _ Gh wE CO 1�E�4 CL EA/V .SA/V,0 •.�: BACKF/C L L/QU/O LE1�FL 4..CAST i /R.QN P/PE i /d o a A a o a OF SEPT/C TANK D/sT, o e s: • • • • e'�♦ e o . WA3HF0 S72�NE LV31 ° s. + • • G EG'T• L WA5N D .STO/YE �PITt/ �, :. • • • • • • r• o p PREcA5T.SEEPAGE 1NrVi A"r Gl.RVAT/ONS a :., , • .:. • . . , • ( o Q o O/T OR EpU/.✓. L. 89rS /MYERT AT d[//LD/NG 97.19 FT .` G Fr: P%AM. /0I4LE7' SEPT/C Ti4A/K 9 FT. �_ fl fT !�/AM.. C CSE 779 E BULAT1.oN) DUTLET SEPTIC TANK FT, r INLET O/STR/BI T/ON BOX 9'6•° FT SECT/ON OF GROLIND �,gTER TABLE O�/TLETD/STR/B(/7YON BOX 9S9 CT /NLET LEACH//VG 'OT FT SEWAGE .L ISI�O�TAL .SYSTE LEACH/NG TABIILAT/ON scAtf :` %s /:8�, D/MEN.S'/oAf A, FT. DESION CRITERIA Dir�ExBtON $ T. N�lMQER OF BEDROOMS 3 D/HENS/ON. C, y_F T.MIA/; RQA4GED/SPOSAL UNIT 0 SOIL LOG raTAL EST11#% TED FLopv r33 fl Gat.�DAY SO/L TE5T 0/. SO/L TL=•STs*2 ' SO%L TEST NUMBER AF 4.-.4cKrN6 p/rs_ L_ f�tW✓ ELgY. 96, 5" p.4TE OF`SO/L TEST '`7� ✓ a"� /�I�� S/DE LEACHING PER PIT Lam _SQ, FT. 0 . '_ ' RESt/LTS IV/TNESSED B' +►n ► 'r i 40' 6oTTOML.E,4CN/NG PER P/T 7V S4 T. LaAM. REACOLAwo" /IA7'IE•01 -,wlmo+I/NCH TOTAL LEACH//1'G RREA 26G sop. FT. S�/215,0/4 S06So/L IWtC0L/47'/ONRArE.*2 7-71g,11-4/M/N./INCH RESER{iEGEA CIA,//V6 AREA b so. FT. , r Z'.0 r SH of ssq S.4 s�l� rV� Lv T z , �A�/J�° .S` 1 :iDi' 1J- S moo? ROBERT tiG P. rnr BUNIKIS - A No.22162�0 Q tOREDGEE EfJ�/MG CO,ING. E NG/N 90 Q/STE �� EL; 8S� D. CL. ¢-5": 7/2 /r A,N sr. ONAL�� NOGROi/ND YYi4TER !.c/VCOU/YTERL�p NYANN/3 GROI!/V!O VV.ATEAP:Al— EL£i/.