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HomeMy WebLinkAbout0127 CEDARWOOD ROAD - Health 1.27 CEDARWOOD Cotuit - - - - - - -- -- - - - - A = 019 049 i I COMMonwealth of Massachusetts Title 5 Official Ins - Subsurface Sewage Disposal System F�����f ®� Voluntary Assessments Property Address �Sl� ^ Owner Owner. ©� W ! 1��`� / information is s Name eeeLLL/// ��•I�C� required for every 1 _ Lu_ page, City/I own r/�// 0-� State Zip Code Date of nspect on Inspection results must be submitted on this form. Inspection forms may not be alters way. Please see completeness checklist at the d to an end of the y of form. Important:when filling out forms A. Genera 8 Information on the computer, use only the tab 0 key to move your 1 Inspector: cursor-do not7�use the return a✓�- key. Name of Inspector � Company Name �o �� Company Address ran City/Town �� A d� o State— — - ra 2a Zip Code 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 CM 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Nee Further Evaluation by the Local Approving Authority 7/� 4 a I L�0 Inspector Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / Property Address ��0� t/ou C �d Owner Owner's Name C. information is required for every d A1,4 �] page. City/Town f7�` oa State Zip Code Date of Inspe tion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) ;,te sses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure crita not evaluated are indicated below. eri Comments: 8) 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M Property Address Owner Owner's Name �ISC'0 information is _1 required for every roTIP t page. City/Town B. Certification (cont.) State Zip Code Date of Inspection ❑ 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 to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. Systemuwill 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. I. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts y Title 5 Official Ins - Subsurface Sewage Disposal System F��m � 'f®Voluntaryr Assessments 4M V f�d Property Address v VVO` Owner information is Owner's Name /0 1 A required for every l/ 'moo 8 /- Al aa(,SS page. Clty/Town State Zip Code Date Inspec on Bo 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 ❑ L� 111" Static liquid level in the distribution box above outlet invert due to an overloaded I clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts N Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments U/ C//) Property Address Owner 's information is Owner Name required for every o 7 l�► m�/ ��page. City/Town State Date of I pection Zip Code �� Certification (cont.) Yes No Required Pumping mor❑ p p g e than 4 times in the � bstructed pipe(s). Number of times pumped: ast year NOT due to clogged or ❑ l� Any portion of the SAS, cesspool or privyis below high g 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 P 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 ystem is a cesspool serving a facility with a design flow of 2000gpd- 0 000gpd. ElThe 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '4 M /J�Property Address Owner pwner's Name information is _ required for every ®��e a�6 page. City/Town C. Checklist State Zip Code Date of I pection Check if the follow* g have been done. You must indicate "yes"or"no"as to each of the following: Yes o ❑ m'ping information was provided by the owner, occupant, or Board of Health ❑ ere an of the system y y tem components pumped out in the previous two weeks? ❑ as 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 3o t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C��.,/!�o c� Property Address Owner information is Owner's Name iT�C. 3� required for every � ` �' � [/ Le page. City/I own State Zip Code Date of I spection D. System Information Description:.13) (0 4 Soo G-c, At, 646.���� 13 , 33 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes R No Water meter readings, if available (last 2 years usage (gpd)): Detail Sum pump?p p p ❑ 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: 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 1 r Commonwealth of Massachusetts Title 5 official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1-7 Property Address C-e` ciKI-W-®`)d Owner Ow �1,r C a ner's Name information is required for every co_l^ 7"46 page. City/Town State Zip Code Date of spection D. System 91� Ormation (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: p2 0 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 Sys m: 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I � Commonwealth, monwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form v Not for Voluntary Assessments Property Address Owner User, 's information is Owner Name required for every 60-�4 a page. City/Town State Zip Code Date of I rif D. System Information (cont.) pectin ApproximIN/ t age of all components,��/7 stalld (if known)and source of information: �/ y- Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: !/ Feet Material of construction: [Icast iron 40 PVC ❑ other(explain): �- Distance from private water supply well or suction line: feet /C) Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material onstruction: concrete ❑ metal ❑fiberglass 9 ❑ 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: �/ 1 Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 ill Commonwealth of Massachusetts H Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9C4 iZi Y Property Address /dr / Owner Owner's Name information is required for every page. City/I own S—tale—1 -it Code d / P Date of Ins ection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness /� o �� Ld Distance from top of scum to top of outlet tee or baffle �— Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? �-t?///Ct_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 0/111#'I dO T (�- -PiC"PiC• G� "ts GH ce s ✓t �oCl/ /V0 Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass g ❑ polyethylene El 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner �Is CI 's information is Owner Name required for every O�Litt �� �� P page. CitylTown State Zip Code Date of I D. System Information (cont.) Pection 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 Bolding 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal al System Form _ Not for Voluntary Assessments Property Address Owner Owner's Name information is _ required for every A� page. City/Town State Zip Code Date of I pection D. Systems Information (cont.) Distribution Sox(if present must be opened) (locate on site plan): _ Depth of liquid level above outlet invert L-- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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 p n why: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Property Address daA"o 0 I Owner Owner's Name information is required for every page. City/Town State Zip Code Dat of nspecti n D. System Information (Cont.) �✓ !� 33� Type. ❑ leaching pits number: ❑ 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.): / a s rc' C 14.,y 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c4 /� Property Address C/,�,v C""o 0 Owner Owner's Name Pd�L,® information is t required for every ®° /Ca� page. City/Town State Zip Code Date of I D. System Infoll-mation (cont.) pection 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 1Z f Commonwealth of Massachusetts v Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �a 0 �d Property Address Owner ®® Owner's information is Name required for every o U/ /��page. CitylTown State Zi Code p Date of Insp ction Do 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 whe�puiater supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately / p ® �lf�d'b�a3Po� .3 U Soo I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official _ Inspection Form Subsurface Serfage Disposal System Form - Not for Voluntary Assessments Id 2 Property Address Owner �t.5 co Owner's Name information is required for every D 444, �� (���J/A r2 c/ page. City/Town State Zip Code Date of In pection l D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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 ;---�Checked served site (abutting property/observation hole within 150 feet of SAS) wi local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must d ibe how you established the high ground water elevation: 1 YIS411 b 14, 4 Wo Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For i Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments essments e' M Property Address Ce c � ct/Oo 1.2l Owner /Isco information is Owner's Name required for every page. City/Town � Lf State Zip Code Date of I E. Report Completeness Checklist pectin Inspection Summary: A, B C D or E checked ;EO'_�Ilnspction Summary D (System Failure Criteria Ap plicable to All Systems) completed Sys Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 817/14 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 forrrls A. General Information on the computer, use only the tab 1. Inspector: I key to move your cursor-do not Trevor Kellett use the return Name of Inspector key. Aardvark Environmental Inspections ad_tjCompany Name PO BOX 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-292-1056 S113744 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 Mil 15.000).The system: ~ ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs F her aluation by the Local Approving Authority Age-. 8/20/14 _ 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 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•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 e t Commonwealth of Massachusetts Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form=Not for Voluntary Assessments a 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 8/7/14 page_ City/Town state Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: j ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 6 l 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. P 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. ❑ N ,❑ ND(Explain below). t t5ins•3113 Title 5 official Inspedon Forth:Subsurface Sewage Disposal System•Page 2 of 17 a y i Commonwealth of Massachusetts i- �- Title 5 Official Inspection'Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t " 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 8/7/14 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 pipes)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): r ❑ 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).- El 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)(4)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•3113 Title 5 Official Inspecdon Form.Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts - F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 817/14 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: I . t ,) ❑ 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. I ❑ 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: t Yes No ® El -clogged of sewage into facility or system component due to overloaded or • clogged SAS or cesspool a 1 ❑ ®' 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'1/day flow t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for:Voluntary Assessments 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 817/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. 1 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 El 1-1 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. t5ns•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - UuTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name requiratfore Cotuit MA 02635 8/7/14 required for every page. City/Towri 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? IR ❑ 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•3113 Title 5 Official Inspection Form.Subsurraoe Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is Cotuit MA 02635 8/7/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information r. Description: i Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 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/scl t:, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? • ❑ Yes ❑ No Non-sanitarywaste discharged to the Title 5 system? ' Yes No 9 Y ❑ ❑ Water meter readings, if available: ft5ins•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 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is COtult required for every MA 02635 8!7/14 page. Cityfrow n State Zip Code Date of Inspection D. System Information (Cont.) P� . 1 ; . 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 r ❑ 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): t5ns•3113 Tille 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 8/7/14 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: 25+years appr. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1.6 Depth below grade: feet Material of construction: El cast iron ®40 PVC ❑,other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): looks like it was replaced Septic Tank(locate on site plan): cesspool Depth below grade: n/a 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: n/a cesspool Sludge depth: n/a cesspool t5ins•3/13 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official InspectionwFoem Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Cedarwood Road lf.I- Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 8/7/14 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 n/a cesspool Scum thickness n/a cesspool Distance from top of scum to top of outlet tee or baffle n/a cesspool Distance from bottom of scum to bottom of outlet tee or baffle n/a cesspool How were dimensions determined? n/a cesspool Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,-evidence of leakage, etc.): n/a cesspool 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 Distarce 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 t Commonwealth of Massachusetts Title 5 Official Inspection: Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 8/7/14 • 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 worldng 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 Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner owner's Name information is required for every Cotuit MA 02635 8/7/14 page. Cityrrown 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 n/a 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.): 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: t5ins•3/13 Title 5 Oltldal Inspection Form:Subsurfaoe Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Nam information is Cotuit MA 02635 817/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ 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.),. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 6" 9 Depth of solids layer Depth of scum layer 5 Dimensions of cesspool 6x6 Materials of construction drywell blocks Indication of groundwater inflow ❑ Yes ® No t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection'-form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 8/7/14 " 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.): ' Cesspool filled almost to top within 6"of inlet with scum on cap indicating backup and failure 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 f { Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 8/7/14 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 Back 65.5' - 90.5' • 1 t5ins-3l13 Title 5 Ofidal Inspection Forth: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 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 8/7/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r, Site Exam:. ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 45 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 locail Board of Health-explain: ❑ Checked with loca€excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS Maps show test hole on property at 44.3 feet Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3/13 Tithe 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 127 Cedarwood Road Property Address BONAIUTO, MARK L&MARIANNE Owner Owner's Name information is required for every Cotuit MA 02635 8/7/14 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 Z System Information—Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Offiaal hVection Form:Subsurface Sewage Disposal System•Page 17 of 1T No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Disposal *pstrm Cuns"ttion 3permit A plication for a Permit to Const t Repair(4 Upgrade( ) Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 6 J t.y 8 1 Z Owner's Name,Address,and Tel.No. Rosc1.4 t3�a►1 Assessor's Map/Parcel Q 19 oar Wo 12`1 Cectar W OOCL Re( Co- v, 4 Installer's Name,Address,and Tel.No.$i 13 Designer's Name,Address,and Tel.No. SW& Worlt$ )q-r"!�crry wi fares4e(e,Ic. y9q). 0653 IZw/csq Cros IrsC)Cl Rd Feftsiddlc `I.7.1. 5313 Type of Building: Dwelling No.of Bedrooms 34 J Lot Size yG_ L 9 i sq.ft. Garbage Grinder( ) Other Type of Building Rc,s i J c•n-1,*J No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ANS gpd Design flow provided ys y gpd Plan Date Number of sheets Z, Revision Date Title Size of Septic Tank /Soo Type of S.A.S. (3) Soo 9 a) c�ca r..S Lf S Description of Soil Nature of Repairs or Alterations(Answer when applicable) Tnn .D BO X • LcGIC,1; n9 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 Certificate of Compliance has been issued by this Board of Health. Signed Date $-Z 17 •14 Application Approved by Date lr'.V� - L( Application Disapproved by Date for the following reasons Permit No. 9 0(L( Date Issued i tx rs ' •� • No. � ta y(L i I ! N' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS \ 2pplicatlon for llisposal 14pstem Construction Permit j pplication for a Permit to Construct( Repair ,/S Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. L i f G y fj 12� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel p 9 _ 0 y 9 r j 2`1 Ccotar w 0001 R j C o-I o f Installer's Name,Address,and Tel.No. (36:ee aJa-)1 0n Designer's Name,Address,and Tel.No. 4\� l� TcaSerr•� !.N fares-►a1Q Ic ` y97• p G 5 3 IZ t.,1es'I C'roSS�';tlol 62a FvreSido.l e y77 • 5313 Type of Building: .J Dwelling No.of Bedrooms 34 ) Lot Si�ke�ar- G G 9 �•-' sq.ft. Garbage Grinder( ) Other Type of Building d1 ) No.of Persons y* ' ;' �Sh wers( ) Cafeteria( ) (le 5, c��; Other Fixtures d Design Flow(min.required) y y Q , gpd Design flow provided S y, gpd Plan~ Date I r_f Number of sheets 7 Revision Date Title Size of Septic Tank ,/SOO Type of S.A.S.�3)_,500 q 0.) Description of Soil - Nature of Repairs or Alterations(Answer when applicable) Tn n}! • O x a c 4 s 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 Certificate of Compliance has been issued by this Board of Health. 1 Signed Date • 2 7 • L) Application Approved by Date �( 4 y Application Disapproved by r Date for the following reasons Permit No. ep of c( �j Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓f Upgraded( ) Abandoned( )by C E X Ca U,,,I ;O j at 1 7'7 r r,i ncr( Re-,k_ ( cH v;-t has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.,,,al l t— { dated Installer _(3 _(j Ex c a�/cz 1 ;o y Designer E YJ L (wl o r K S #bedrooms y Approved design flow gpd T The issuance of this permit sh 11 of be tr#d as a guarantee that the system w'-7 function d signed. ! ��/✓� '� f`��14 Date Inspector L v �y / , No. d p L� — - + Fee I �V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(v/) Upgrade( ) Abandon( ) System located at 12"7 (�c�arrA�ood 1". Onqy; f and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be leted within three years of the date of this permit. e T Date r I Icom Approved by Town of Barnstable Regllaory Services Thomas,F. Oeiler,Director a Pub lieieal Divon Thomas McKean,Director ' 200 Mam Street, Hyannis,.MA 026.01 Office: 508-%24,644 Fax: 508-7904 04 Date: 3 t"1 _ Sewage Permit#AQ �"essor9s Map/Parcel Installer.&R,eI,=' r Ce0Mca:tion Form Designer: t✓n�,; n:era,r, ,;r,� liyorLcsi Jnc , Installer: �G`!0` 6v` Address: I2 W, C rb s 5 e l el IZ4, Address: 14 I-e S 6cx' : M A- rc��e In'l A— On S•2-q-t y �} �,cG�,�►a was issued a permit to install a (date) (installer) septic system at ill Cecl based on a design drawn.by (address) eIP51 -N.c.7crv) V-l- rl * ILtC dated 7 —7 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any.component Of the septic system) but in accordance with State & Local.Regulations. Plan revision or certified as-built by designer to follow, Stripout (if required) w cted and the soils were found satisfactory. �y (i 2 �d PETER T . (Installer's Si a ! _ McENTEE ; ) Cin y Q esig n er's Si atme Affix Desi PLEASEw TURN TO BARNSTAHLK P.URLIC;II ALTH DIVISION CEIRTI CAT- OF COl«LUNCE WILL NOT BE `ISSUED TIL BOTH THIS FORM AND, AS. BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. L gaoffice formAdesignercerdfication form.doc TOWN OF BARNSTABLE LOCATION J Z) Ccdartaood RJ- SEWAGE#Zo14 -30 VILLAGE ASSESSOR'S MAP&PARCEL D 19 - p y9 INSTALLER'S NAME&PHONE NO. _QA B EXCckJcL4►on - 4197- OLS3 SEPTIC TANK CAPACITY JSOO qct I LEACHING FACILITY: (type) SOOQa1 ckaM,� (3) (size) 13 x 33 x Z NO. OF BEDROOMS y OWNER 4 Br—ml PERMIT DATE: $- Z 9-J COMPLIANCE DATE: 9. Z - /y Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 1 Al- 23 � 31' 43 ' AZ. ZsZ. 82. qg.z.., REAR A3. 3� B3' Ay - 4o',6" . � y 3 rG._ Town of Barnstable P# ' Department of Regulatory Services at,u Public Health Division Date t6J9. ��Y 200 Main Street,Hyannis MA 02601 fD�I.A �l Date Scheduled l Time Fee Pd, Soil Suitability Assessment for Sewage Disposal Perfonnedly: M-C L'^� SE-A /S Z Witnessed By: �D/l //�S �q ItS 1� LOCATION& GENERAL INFORMATION Location Address I Z7 Ceda,rGvvp-a 2t,4 a Owner's Name Address ­73 Assessor's Map/Parcel: '-L� Y 9 Engineer's Name Q NEW`.CONSTRUCTION /` REPAIR S Telephone# -5,0 7-737-47 6 b Land Use �CS��n�'' + Slopes(%) r— Z Surface Stones NsrV(11 Distances from: Open Water Body-??ae ft Possible Wet Area N/ ft Drinking Water Well tab ft Drainage Way ft Property Line 6C�� �'_ ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands?n proximity to holes) a --Iz7 .-, ,p .z. S v ew A k� Parent material(geologic) 41 U�`� Cis Depth to Bedrock Depth to Oroundwater. Standing Water,in Hole: N Weeping from Plt Face AJ'^� it Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to still mottles: ln, Depth to weeping from side of obs,hole: in, Groundwater Adjustment ft. Index.Well# Reading Date: Index Well level ,., Adj,thetor— Adj.10idundwater Level ,e PERCOLATION TEST Date. Time, Observation Hole# _ Time at 9" Depth of Pere 2 Z Time at 6" Start Pre-soak Time® _ ?� t;%t\6 'rime(9"41) End Pre-soak pl a,rt eC� ✓l IeSS Rate Min:/Inch. Z ? 1 '-k LS,'`'- Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one(1) week prior to beginning. Q:4S EPTIC\PERCFORM.DOC DEEP.OBSERVAt 1 HOLE LOG Hole Depth from Soil Horizon Soil Texture Sdil:Color Soil . Other Surface(in.) (USDA) (Munsell) Mottling (Structure;Stonea;Boulders. Consistency.. Gravel) ©—S A Ls lo�i2`l�z o `CrZS�� z.�-12d C K,SAY.,d Z,5y6,N DEEP OBSERVATION HOLE LOG Hole# �- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.,Boulders• Consistency, —� X y(Lq) z �o 514 DEEP OBSERVATION HOLE LOG Hole# 3 Depth from Soil Horizon Soil Texture Soil Color Soil' Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. at� Yle- s O S"r�• •Z DEEP OBSERVATION HOLE.LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, 0 0 �S 7 2� _i32 (4-eA .Sdi st, Z,S y Cc Flood Insurance Rate Map; Above 500 year flood boundary No_ Yes Within'500°year boundary No Yes.;. Within 100 year flood boundary No 0� Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout;the area proposed for the soil absorption system? e—} If not,what is the depth of naturally occurring pervious material? Certif cation by the ed ,� 1�a�5 ' I certtfy that on (date)I have passed the soil evaluator examination approv Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 10 CMR 15.017. I Date Signature �=T 23 l QrtS.Ep nC%PERCFORM.DOC -IXlS71NG S.A.S. 42 -- EXISTING CONTOUR N _ - y (APPROXIMATE LOCA770N) x 42.98 EXISTING SPOT GRADE �'Os I TO BE PUMPED, FILLED WITH4) SAND AND ABANDONED N/ EXISTING WATER SVC. A a N \ 1 G EXISTING GAS SVC. School Street 'OI -__0 H: l/tf- OVERHEAD WIRES �• All . \ 2S 7`3ObTrs m TEST PIT g LOCUSa BENCHMARK o g 'ems LEGEND cedo`3 a w MBLU 019-049 y Lots 164A & 164B e5 popon 46,691 f S.F. 1.07t AC. LOCUS MAP NOT TO SCALE 98� _F,,�4G CESSPOOL GENERAL NOTES: TO BE PUMPED, FILLED WtR4, { SAND AND ABANDONED 1 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE, LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. o 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE QENCHMARK 98.37 LOCAL RULES AND REGULATIONS. BLOCK DECK FOOTING + 98,15 + 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR EL. 99.35 Assumed + 97.80 / F 99.16 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE / O DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING I PROPOSED / FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN / SEPTIC TANK ENGINEER BEFORE CONSTRUCTION CONTINUES. off, 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. (A N 98.61� 97 P7 96.64 TP-1 TP-2 9g 3 / � � 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF co •• ..........�........ .. W � THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF Lawn _3•_5 �-_�-1_2.8' ^� t: cn - - HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. O 99.31 04 �, ROP. S.l4..S. r i D O w v e 8.6Nr:;° o °ei+3 I p ^ 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. aA b^' ' ,';' :•:•. ::'>'' }• i 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 98.81 F T.L -- _:1 1 '•..D rn (W O 73 TP�4�m i N h 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS �g A i �a + 9,02� = AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE �c + 98.85 _ ! i DIRECTED BY THE APPROVING AUTHORITIES. 0 99,06 99 +' I ' 1 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 13. 99.20 + 99.25 d THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING o 54 Deck ' CONSTRUCTION. E 98.96 of 99.59 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS / 9 9.4 6 3 99. 9.54 ° „ IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND + INV.=98.2t 99.30 ' REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). OF Mgss 99.25'•. GARAGE E%S NG\ °i W 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE HOUSE(#127) INSPECTED BY A LICENSED SOIL EVALUATOR PRIOR TO BACKFILL. o PETER T. ✓ `TOF=100.25 {j 13. THE ENGINEER IS NOT RESPONSIBLE FOR ANY EXISTING UNDOCUMENTED �" 99,31 r SEPTIC SYSTEM COMPONENTS NOT SHOWN ON THE PLAN. McENTEE + ��t39.40 99.63 �{ 99.46 + 99.46 v CIVIL "' v No. 35109 lq6 99.55 '-c ? 1 ::.:3.:.•, OWNER OF RECORD 99.77 BEAL, ROBERT M & JANET M 73 PURITAN ROAD ° + "D WABAN, MA 02168 99.75 170.00' PROPOSED SEPTIC SYSTEM UPGRADE PLAN s 4179'30H E 9 ,56 127 CEDARWOOD ROAD, COTUIT, MA ..,f...; � 99.13 99.31 99.47 Edge of Grovel Rood 99.60, Prepared for: Robert Beal, 73 Puritan Rd., Waban, MA 02618 99.88 Engineering I by: Surveying by: SCALE DRAWN JOB. NO. I Engineering Works, Inc. WARNER SURVEYING 1"=30' P.T.M. 126-14. CEDA R W 0 0 D ROAD 0 12 West Crossfie Road 22 Long Road DATE CHECKED SHEET NO. Forestdole, MA 2644 Harwich, MA 02645 (508) 477-5313 (508) 432-8309 7/7/14 P.T.M. 1 of 2 IL NOTE: TO PREVENT BREAKOUT, THE PROPOSED SOIL LOG FINISH GRADE SHALL NOT BE < EL: 96.5 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. DATE: MAY 28 2013 P#14,339 SEPTIC TANK ' INSTALL RISERS & COVERS OVER INLET & PROPOSED D-BOX PROPOSED S.A.S. I SOIL EVALUATOR: PETER T. McENTEE (SE 1542) OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & COVER INSTALL RISER & COVER OVER EACH CHAMBER AND ENGINEERING WORKS, INC. T.O.F.=100.25 SET TO 6" OF GRADE SET TO 3" OF F.G. TO SERVE AS INSPECTION PORTS WITNESS: DONNA MIORANDI R.S. HEALTH AGENT F.G. EL.=99.4f F.G. EL.=98.5t ELEV. TP-1 DEPTH ELEv. TP-2 DEPTH F.G. EL.=99.3f F.G. EL.=98.6f 98.5 A 011 98.5 A 0" LOAMY SAND LOAMY SAND L = 15' f t 10YR 4/2 10YR 4/2 C� S=1� MIN. L = 15' 704'� 23' 97.8 8" 98.0 6' (MIN.) 5=1% (MIN.) % (MIN.) B B 4"SCH40 PVC 4"SCH40 PVC 40 PVC 2" LAYER OF 1/8" TO 1/2" LOAMY SAND LOAMY SAND 6•• . DOUBLE WASHED STONE 1OYR 5/8 10YR 5/8 10„I as p as (OR APPROVED FILTER FABRIC) 96.5 24" 96.5 24" 14" s aaaaaaa C C •+ INV.=97.25 48" LIQUID INV.=97.00f 6aa®Baa -3/4" TO 1-1/2" DOUBLE PERC WASHED STONE LEVEL 4' 4.8' 4' 30"/42" GAS BAFFLE INV.=96.67 . 6.50 PROPOSED D-BOX EFFECTIVE WIDTH = 12.8' MED. SAND MED. SAND amam Aft INV.=96.00 2.5Y 6/4 2.5Y 6/4 Am wllk� PROPOSED SEPTIC TANK 3-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN CONNECT TO EXISTING SUITABLE SEWER PIPE OUTSIDE HOUSE, INV.=98.2t(verif H-10 RATED TOP CONC. ELEV.=96.8 BREAKOUT ELEV.=96.5 NOTES: INV. ELEV.=96.00 MMIM= SOMease 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPES & aaa® sasses 88.5 120" 88.5 120" INVERTS EXITING HOUSE, PRIOR TO INSTALLATION. BOTTOM ELEV.=94.00 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND 4' 3 X 8. =25 '5' .5 4' NO GROUNDWATER OBSERVED, PERC RATE <2 MIN./INCH TRUE TO GRADE ON A MECHANICALLY COMPACTED 4 OF NATURALLY OCCURRING EFFECTIVE LENGTH = 33.5' SIX INCH CRUSHED STONE BASE, AS SPECIFIED PERVIOUS MATERIAL IN 310 CMR 15.221(2). 5' (MIN.) ABOVE G.W. LEACHING SYSTEM SECTION 3) INSTALL INLET & OUTLET TEES AS REQUIRED. BOTTOM OF TP-3, EL=87.6 =_ ELEV. TP-3 DEPTH ELEv. TP-4 DEPTH 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. 98.6 0 98.8 0 FILL FILL SEPTIC SYSTEM PROFILE 97.6 A 12" 97.0 A 10" LOAMY SAND LOAMY SAND 97.1 10YR 4/2 18" 97.4 10YR 4/2 17" B B LOAMY SAND LOAMY SAND DESIGN CRITERIA ®®®I3 0 ®®®® 10YR 5/8 10YR 5/8 ®®®®®® ® ®®®® 33„ 96.1 C PERC 96.4 C 29" NUMBER OF BEDROOMS: 4 (3 EXISTING + 1 FUTURE) ir ®®®®®® ® ®®®E3 30"/42" SOIL TEXTURAL CLASS: CLASS 1 N z E3 IT®E3®E3 ® ®E3 E01 E3 DESIGN PERCOLATION RATE: <2 MIN/IN - (0.74 GPD/SF LOADING RATE) MED. SAND MED. SAND DAILY FLOW: 440 GPD 102" 2.5Y 6/6 2.5Y 6/6 1 DESIGN FLOW: 440 GPD SECTION k GARBAGE GRINDER: NO LEACHING AREA REQUIRED: (440 GPD) = 594.6 SF 4" KNOCKOUT 87.6 132" 87.8 132" .74 GPD/SF 20" DIA. COVER PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY NO GROUNDWATER OBSERVED, PERC RATE <2 MIN./INCH PROPOSED DISTRIBUTION BOX: 1 INLET, 3 OUTLETS 4" KNOCKOUT 4" KNOCKOUT 58" USE 3-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 127 CEDARWOOD ROAD, COTUIT, MA SIDEWALL AREA: 2(12.8' + 33.5') X 2 = 185.2 S.F. 4" KNOCKOUT BOTTOM AREA: 12.8' x 33.5' = 428.8 S.F. Prepared for: Robert Beal, 73 Puritan Rd., Waban, MA 02618 TOTAL AREA:........................................................... ..614.0 S.F. 500 GALLON CAPACITY, H-10 LOADING Engineering by: Surveying by: SCALE DRAWN JOB.-NO. PLAN Engineering Works, Inc. WARNER SURVEYING N.T.S. P.T.M. 126-14 12 West Cross£eld Road 22 Long Road DAB CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(614.0 SF) = 454.3 GPD CHAMBERS Forestdole, MA 02644 Harwich, MA 02645 (508) 477-5313 (508) 432-8309 7/7/14 P.T.M. 2 of 2