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HomeMy WebLinkAbout0116 CHERRY TREE ROAD - Health 116 Cherry Tree R60A A= 019- 137 Cutuit � -------- ---- - I it i of Commonwealth of Massachusetts 11P Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cherry Tree Road Property Address r Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Nyeinformation is COtUIt �/ required for every MA 02635 3/4/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms p 5141 1SoZ011_0 on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLC use the return key. Company Name P.O. Box 49 r� Company Address Osterville MA 02655 �I City/Town State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further valuation by the Local Approving Authority 4. ❑ Fails 3/5/2021 Inspect Signature Date The s st m inspector shall submit a copy of this inspection report to the Approving Authority (Board of He 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 18 I Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is Cotuit required for every MA 02635 3/4/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts O Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is required for every COtUIt MA 02635 3/4/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is required for every Cotuit MA 02635 3/4/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is required for every COtUIt MA 02635 3/4/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 f Commonwealth of Massachusetts ,F Title 5 Official Inspection Form s age Disposal System Form - Not for Voluntary�i� Subsurface Sew Di y Assessments 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is required for every Cotuit MA 02635 3/4/2021 page. City[Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen'Mcmahon Owner Owner's Name information is required for every COtult MA 02635 3/4/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments z 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is required for every Cotuit MA 02635 3/4/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped on 8/12/2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �;• r/ 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is COtUIt required for every MA 02635 3/4/2021 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: installed on 3/1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is required for every CotUit MA 02635 3/4/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2011 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ 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: 3 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The Tees were present. There was no sign of leakage. Both covers are 7" below t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owner's Name information is required for every COtUIt MA 02635 3/4/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts l-9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is COtUIt required for every MA 02635 3/4/2021 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Even 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.): The D-box was normal. No solids were present A riser was installed t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is COtUIt required for every MA 02635 3/4/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): n/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1- 1000 al. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 'v Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cher r Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is Cotuit required for every MA 02635 3/4/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit had 3' of water on the bottom There was no si n of failure A riser was installed 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of ligaid to inlet invert Depth of solids layer Depth of scum laver Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 116 Cherry Tree Road Property.Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is COtUIt required for every MA 02635 3/4/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts iP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is required for every COtUIt MA 02635 3/4/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 boo r . L. LJ \ A a a o 3 o y Q a3 � air 19 3 30 3 g6 a( t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is COtUIt required for every MA 02635 3/4/2021 page. Clty[Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 17' +/- 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: Topo and water contours maps ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments up 116 Cherry Tree Road Property Address Tom Hoppensteadt& Kathleen Mcmahon Owner Owners Name information is Cotuit required for every MA 02635 3/4/2021 page. Cltyrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I� Oct 06 14 10:35p p•18 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r: 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owners Name information is required for every Cotuit MA 02635 10-1-14 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 and of the form. Important:When A. Genera! Information filling out farms `,��►anllnluapi on the computer, use only the tab 1 Inspector. 0 o.:•` � key to move your . . •' s • o�G�': 9 cursor-do not .lames D_Sears JAM E S use the return key. Name of Inspector a :C„ * *� CapewideEnterprises,LLC � �=,o o;• ffi Company Name ` 153 Commercial Street 5I•N 5 p�G��.�\ �1 - NNnur� -- Company Address rl\l� Mashpee MA 02649 Cityf'rown State Zip Code 508-477-8877 S1623 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 15.00(1). The system: ® Passes ❑ Conditionally Passes ❑ Faits ❑ Needs Further Evaluation by the Local Approving Authority 10-6-14 spectors 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. 15iru-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Oct 061410:35p p.1 g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti _ Owner Owner's Name information is required for every Cotuit MA 02635 10-1-14 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: The system is a 1000 Gal. tank D Box and pit. 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 exfiltratibn 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): 15ms-3113 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 o117 f Oct 061410:35p p.20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owner's Name information is required for every Cotuit MA 02635 10-1-14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval it Pumps/alarms are repaired. 13) System Conditionally Passes (cunt.): ❑ 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 Form.subsurrem sewage Disposal System-Page 3 of 17 Oct 061410:36p p.21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owner's Name information required for every Cotuit MA 02635 10-1-14 page. Cityfrown State Zip Code Dale 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 his less than 6" below invert or available volume is less than Y2 day flow Pi 7— - t5ins-3113 TWO 5 Official Inspection Form:SubaXace Senage Disposal System•Page.40917 Oct 061410:36p p.22 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owner's Flame information a required for every Cotuit MA 02635 10-1-14 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.I have determined that one or more of the above failure criteria exist as described in 310 CM 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 11 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•3113 Title 5 Of6del Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 i Oct 061410:36p p.23 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owner's Name information is required for every Cotuit MA 02635 10-1-14 page. City/Town slate 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 Q ® 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 volume$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 NIA) ® ❑ 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 ISurs-3113 Title 6 ORdal Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Oct 06 1410:37p p.24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owner's Name information is required for every Cotuit MA 02635 10-1=14 page. Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. tank, D Box and pit. Number of current residents: 0 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 Seasonaluse? Q Yes ® No Water meter usage readings, if available last 2 ears 2012�1,00OGal's g ' ( y g (gpd))' 2013-3,000Ga1 s Detail.- Sump pump? ❑ Yes ® No Last date of occupancy: NADate CommercialAndustrial 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 Q No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System•Pegz 7 of 17 Oct 061410:38p p.25 Commonwealth of Massachusetts Title 5 Official Inspection Form a — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owner's Name information Is required for every COtUIt MA 02635 10-1-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes Z 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 Q 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•M3 Title 5 Ofricia:Inspection Form:Subsurface Sewage Disposal system,Page 8 of 17 Oct 06 1410:38p p.26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owners Name information is required for every Cotuit MA 02635 10-1-14 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: 1987 Permit #87-184 Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer(locate on site plan): 40" Depth below grade: feet Material of construction: ❑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.): Pipeing is PVC SCH 40 Septic Tank (locate on site plan): 28" Depth below grade: feet Material of construction: CE 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 1000 Gal. Precast H-10 Dimensions: 3" Sludge depth: i5ins•3113 TNe 5 OfTual Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Oct 06 1410:38p p.27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owner's Name information is Cotuit MA 02635 10-1-14 required for every 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 27" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 1� How were dimensions determined? Asbuilt-Tape 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.): Tank at working level_Tank at 28" below grade w/both covers at 4". Inlet tee,outlet baffle. No sin of jeakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ 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•3113 Title 6 Official inspection Form:Subsurface Sewage Dispoeel System•Pepe 10 of 17 Oct 061410:39p p.28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owner's Name information is required for every Cotuit MA 02636 10-1-14 page. City/Town State Zip Code Date of Inspedlon 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: Dare Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.3/13 Tine 5 Official Inspsclion Farm:Subs"oe Sewage Disposal Syslem•Page 11 9'17 L_ Oct 061410:39p p.29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Ownees Name information is required for every Cotuft MA 02635 10-1-14 page. Qylrown 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.): D Box is 16"xl6"-3'below grade w/one line out. Box is clean and solid. No sign of over loading or solid carry over. 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: Nns•dry 3 Title 5 olfidal Inspection Forth:Subsurface Sewage OispoeM System•Page 12 of 17 r Oct 061410:39p p.30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owners Name _ information Is required for every Cotuit MA 02635 10-1-14 page. Cityfrown 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: ❑ teaching 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.is Leaching is a 600 Gal. Precast Pit w/4'stone per plan. Pit at 5 below grade w/cover at 40"_ Pit is dry,No sign of over loading or solid carry over. 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 !Sins-3r3 Title 5 Official Imeetion Form:Subsurface Sewage Disposal System-Pegs 13 of 17 l Oct 061410:40p p.31 Commonwealth of Massachusetts ry Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti _ Owner Owner's Name information is required for every Cotuit MA 02635 10-1-14 page. City[Town State Zip Code Date of Inspection D. System Information (cons.) 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•V13 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 14 of 17 ill Oct 061410:40p p.32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owners Name information is inquired for every Cotuit MA 02635 10-1-14 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 2 3 P �3 = z14-7� A 6 6-.3 _ CIO � - `/ - A O w G 15ins•3113 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•page 15 of 17 L_ Oct 061410:40p p.33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner Owner's Name information is CotUit required for every MA 02635 10-1-14 page. Cltylfown State Zip Code Date of Inspectlon D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Al'Estimated depth to high ground water: 13' 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 7 — 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: T_H. on design plan 2-24-87. No G.W. at 13'. Bottom of pit at 9' below grade. Bottom of pit at 4'above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. 16ns-3113 Title 6 om aal Inspection Form:Subsurface Sewage Disposal System-Page 1 s of 17 Oct 06 14 10:41 p p.34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 116 Cherry Tree Road Property Address Bernard Centofanti Owner information;s OwnePs flame required for every Cotuit MA 02635 10-1-14 page. city/Town State Zip Code Date of Inspedion 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-3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 17 01 17 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 0 ------- ----- --- --- ...................OF.......................................................................................... Appliratiou for Bhgpas al Works Tomolrnrtuan ranfit M I �- l3� Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..............._ 1.1 _.. rr - ........................... o_.T.....---�....�---�- -- ,.T z. ....f�. . Loca on�Addr _ - or,Lot No. Owre , . Address •---------------- ...... ............. ........•-------••-••_• ••--•-•--•-.........................,_:_. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............. ........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ..................... w Design Flow..................................f______..gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacityh,4_!_2gallons Length................ Width.............:.. Diameter------.---__-___ Depth................ Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...4 BeAo..... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - '� Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --------•-------------------------••----••-•-----••----•---------...----------------•--•-------••-•.......................................................... 0 Description of Soil................................................................................................................ ................................................... w UNature of Repairs or Alterations—Answer when applicable__---•----------------------------------------------------------------------------•--•-•-____-. -------•-----------------------------------------------------------------------•----•--•-•------...........------------------------------.......-----•••-•--•-•-----•-•-----••----••---...---••-.._-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ed by th boa of h Signed -------•---•••-- •-•--- ------------------------- Date Application Approved By........................:..........................-• ............. ...... _ Date Application Disapproved for the following reasons:......... . ..................... .. .. ... . ...... .. ..................................... ---------------------•-----------------------------------•---------------.....-----------....-------------•----•-----•---•---•-••••••--••-•----••-•------------------•-•-•---.......................... Date PermitNo....4F- -�--.f-.9..7--------------•------.. Issued................................................. Date 4-' o;' No. .7 .... ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. ......................OF..................... ..........1.11,....................I......................... Appliration for Dispaaal Works Towitrurtion run fit Application, is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ................ /7 ------ ---------------FL ------•--------------­-----------7­------ ............................. -------- ion or Lot No. -------—-----------"........*---------- -------------------*--------. ......... ............................................. " L ow I Address ................ ............... ................. ................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms---*"*........­t'­.......................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures ....................................................................................................................................................... Design Flow.................................. 7........gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank=Liquid capacity/' � .gallons Length................ Width....._...._..... Diameter.._____......... Depth.............._. Disposal Trench—No. .................... Width_....____....__..... Total Length.._................. Total leaching area-----_------------sq. f t. Seepage Pit No ...... Diameter.................... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water____.._....._......_.__. Test Pit No. 2................minutes per inch Depth of Test Pit._._._._........_... Depth to ground water..__.____._..__......... ............................................................................................................................................................. 0 Description of Soil......................................................................................................................................................................... W U ........................................................................................................................................................................................................ ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable._...............................................................................•.........._._. ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board?ofQ.Ath_, Signel'.t = ';., ......................... .... ................................. Date Application Approved By........................................................".2...................... ................................... 7K, ...... Date Application Disapproved for the following reasons:....._..­1 ................... ... ......................... zi_>4�_ __t�---------- .................................................................................................................................................................------ ............................... Date -7 IssuedL...................................................... Permit No.Z.-J,..... .. .............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 'I I --c...................................... ........... ..............OF.....ta Trdifiratr of TomVIiana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired I by------ --C" ' 46� .... ...........................................................................................................................................Installer at....... ti.te,......... . ............................................................................................................ has been instilled in accordance it'a the provision-, of TILTIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_._.._____._.___-__________..___........._...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. ­7 — � Inspector.....DATE.........46......................t....).................................... ... ..... --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH II ... .............0 F...... To..0 .. .... u............................................ -- . .....2 ................. ........X- FEE..,.. Uhiptial Works TDOnstrudion "Pautit Permission is hereby granted.......cent,!(.......... ........... ................................................................................... to Construct or Repair an Individual Sewage DiMposal System at No..- 4'.ez.�T--------�L------- ...........0...... .........***-------­-------------- Street 'p 1 as shown on the application for Disposal Works Construction Permit N .:16'... .... Dated...... ------- ....... ............................. .................C ­% Board of Health ti DATE.......... 1.2.................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 1, I� SITE PLAN sNEEr i of 2 SCALE: l". 1-o? c I 13 � N lea ,I \ 3 \ ' � � D 42 Joao a hrepric fiA�}�- o p�pp�y p 5 G.A�' - Al (ADO Gr�L � AL�' Dnx i 4 i g 'O D�o >✓X 1 ' �� - i i � r O �syl OF Y M. Vl4 RWICK i No. 19/!1 O F �fcrstt�`�° t t��o s FOR_ C� rG �Z.,�• ,V D �c � �� � - i REGISTERED LAND SURVEYOR ZONE Gr-;,7 U 1'1' , M A 4i,,? . I� cal Z� 1��7 �ZYG1�32 PLAN .REF. Ahh l�h, MA I� I,o'!' l'�7 OATE BENCH MARK DATUM yM1�: WM. M. WARWICK 8 ASSOC:, INC. DOMESTIC WATER SOURCE_Ty�� W �r� �-- BOX 80/ - NORTH 'fA L MOUTH fi FLOOD ZONE. ►� drJ 1-1 AAA iZCD �G MASS. 02556 - (6/7) 563 -2638 f i , LEACHING BASIN SECTION NOT TO SCALEj, , shcc/ 2 e f Z { �Ir • 24 C.1.MH COVER EARTH F/L L BRICK AND MORTAR COURSES AS RE0l0• TO BRING 5 ¢" •- s i _ COVER TO GRADE 4 +B'FLOW LINE INLET _ __ __:;L;•,_ 2'�-y"TO "WASHED PEAS TONE FREE OF IRONS PIPE T. FINES AND DUST /N PLACE " / y" •, •• �/ TO I%"WASHED CRUSHED STONE FREE Of :1 � � � �•'• �' OPEN/NC W/TH 4/8 Q" 2 " OUTER DIAMETER IRONS, FINES AND OUST IN PLACE ANO 13/q"INS/DE .'. a- DIAMETER I. CONCRETE TO BE 4000 PSI 28 DAYS 2. REINFORCED WITH 6"x 6" NO. 6 GA, W.W.M. ' 3. 2'AND 4' SECTIdNS ARE AVAILABLE FOR • GREATER DEPTH REQUIREMENTS � I 4'0" 60" , —� 4. NUMBER OF PITS REQUIRED MIN. NOTE: EXCAVATE TO ELEVATION �. OR EFFECTIVE DIAMETER 1 (NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL WATER TABLE - LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN TYPICAL PROFILE GRAVEL TO DESIGNED GRADE. /8"STD. LT. WGT. C./.MH COVER 2,v a: 4"C../.PIPE 4"8/T.FIBER P/PE TIGHT JOINT ' OUTLET LEVEL DWELLING _ FLOW LINE TO FIRST JOINT0,0 --n� Z .�D 110 �001 � C.I. TEE Z�77 y ,?, ` 1 (0 00 1 1 1 11000 00 1 1 11 23•�l TD, PRECAST CONC. : Z3� I D/ST. BOX TO BE Z3,00 ' '1 0 DO 00 1 1 1 1 , :LQGAL.SEPTIC TANK 1 0 00 0 0 0 1 1 1 INSTALLED ON LEVEL, 1 1 •'a' ;g STABLE BASE 1 1; 000 00 ;,' I I 11 100 00 11 SEPTIC TANK TO BE 1 '1 000 00 1 11 1 ; INSTALLED ON LEVEL, 111 100 I O 0 I 1 ' 1 STABLE BASE. 111 100 11 ' LE 11100 001 11 ACH/NG BASIN ; 1 I 1 I f p 0 0 0 0 1-1 1 BASE TO BE L EVEL 1 1 1 0 1 1 , , { SOIL AND PERC. DATA �•!v?j3l PERC. RATE Z MIN. /IN. TEST PIT NO. I TEST PIT NO. 2 hJ ll(if� t,p 0 11 vP 0.1, Z TEST BY� — •/hv��aILI � � �•� , WITNESSED. BY: 1244 Me, �APA1.J TEST PIT GR. EL. 1 0 ��' #2 �I.20'd-. GL6-Aft hA�D _ GI�rGDriJ haND DATE: A No V✓AIV E CV lS DESIGN DATA GENERAL NOTES BEDROOMS � NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL- tJ0 SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFLal0_'GPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK 000 GAL ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE SIDEWALL AREA 7'�GAL./SQ.FT. TO REVISED TITLE 5 OF THE-STATE ENVIRONMENTAL CODE, MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA �'� GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY I , 1977, LEACHING REQUIRED _t SQ.FT.. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD , ACTUAL LEACHING AREA OF HEALTH. tL2:�_SQ.FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACK FILLING,.THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. I . . PITCH ALL SEWER LINES I/41 / FT. UNLESS INDICATED OTHERWISE I). Y . u SEWAGE DISPOSAL SYSTEM r"1. ' MARTIN 9c o E. ;�, FOR' /� � A L 2 A� T I -� w MORAN 17 �/D 2 GT1 �/� I � i1G (20A.C-1 ' I NAL ia SCALE AS INDICATEO DATE FYI,- G WM, M. WARWICK 8 ASSOC., INC. . r ' 80X 801 — NORTH FAL MOUTH ` MASS. 02556 - (617) 563-26,38 PROFESSIONAL ENGINEER ,+_ F 4 u1r6 TOWN OF B.A NSTABLE v LOCATION r. �1 f., 1I'a � ;SEWAGE # f �l d. VILLAGE ASSESSOR'S MAP & LOT -.13- (INSTALLER'S NAME & PHONE NO. CCt r rum 2 SEPTIC TANK CAPACITY a .01 `LEACHING FACILITY:(type) (size) �O. OF BEDROOMS PRIVATE WELL PUBLIC WATERS BUILDER OR OWNER DATE PERMIT ISSUED: `$ DATE .COMPLIANCE ISSUED: VARIANCE'GRANTED �FXes r" No z + i+ 1.