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HomeMy WebLinkAbout0082 CLAMSHELL COVE ROAD - Health I 82 CLAM SHELL COVE RD., COTUIT No. 0 ��� �'� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9ipfieatiou for Bisposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 2�1, GL jlL_$(14 U_f 0 V6- Owner's Name,Address,and Tel.No. 0,041> M i Assessor's Map/Parcel 00 O 0 c,- 2 G L -i' Installer's Name, ddress,and Tel.No. ja-47Z-8877 Designers Name,' Address,and Tel.No. c�n�caca€�Aog� e 5C)0 w, t�s lei l Type of Building: / Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision/Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) S1U�; Zy , (j tk) -4o ]p a©K 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 C C Date �'•Z�'� I Application Approved by M Date t_ Application Disapproved by Date for the following reasons Permit No. W i lf ( Date Issued �r I �1 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION.- TOWN OF BARNSTABLE, MASSACHUSETTS Application for Disposal 6pstrin Construction 3permit Application for a Permit to Construct( ) Repair(y Upgrade( ) Abandon( ) ❑Complete System ndMdual Components Location Address or Lot No. �, (1�. v tJG Owner's Name,Address,and Tel.No. Assessor's Map/ParcelO�D Installer's Name,Address,and Tel.No. Z'C&477-8971 Designer's Name,Address,and Tel.No, Type of Building: s. Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures x Design Flow(min.required) gpd Design'flow provided gpd Plan Date Number of sheets Revisio ate Title Size of Septic Tank Type of S.A.S.. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Sx)stp 6 r,,N/Lal 4 �,(.J y 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 Application Approved by P6 mt4 aDate _ -� ►l� Application Disapproved by i Date —� ` for the folio nwi g reasons - Permit No. Date Issued Qi lG --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compiiante V HIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) ' Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dated Installer(2� ,�, /Q,4&-Vqc jS ( Designer �z #'bedrooms Approved design flow and The issuance of this permit hall not be construed as a guarantee that the system will-function designed. -Date- �� ,-Z o � �`-'{ Inspector --------------------------------------------------------------------------------------------------------------------------------------- No. /^ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) ,Abandon( ) System located at t , 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 completed within three years of the date of this permit. Date 1a 1(i Approved by —�j- L, � � �- u Commonwealth of Massachusetts 0060- 0:7-f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 82 Clamshell Cove Road Property Address Michael Burke t � Owner Owner's Na e , information is required for every COtUIt MA 02635 9-3-19. 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. IN r) i Important:When e A. Inspector Information filling out forms p S-1# lgli30 ��o`��.• Sy'��,� on the computer, • G� use only the tab James D.Sears _ JA M E S m key to move your Name of Inspector =v: RS ;-+ cursor-do not *: :co c Capewide Enterprises use the return *c key. Company Name '.��1 ��RTI—F�0 o 153 Commercial Street I>'��i�F s j N gpEO`�o``�� r� Company Address Mashpee MA 02649 City/Town State Zip Code few# 508-477-8877 S 1623 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 Evaluation by the Local Approving Authority 4. ❑ Fails 9-4-19 spector'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 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. 15insp.doc•rev.7/25I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form I1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Clamshell Cove Road V� Property Address Michael Burke Owner Owner's Name information is required for every COtUIt MA 02635 9-3-19 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: The system is a 1000 Gal. Tank D Box and pit. 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 I Commonwealth of Massachusetts - : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 page. City/Town 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 2 W. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every COtUIt MA 02635 9-3-19 page. City/Town 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 r t Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,•� 82 Clamshell Cove Road..L,., d Property Address Michael Burke Owner Owner's Name information is required for every COtUIt MA 02635 9-3-19 page. City/Town 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 his less than 6" below invert or available volume is less than 1/2 day flow ✓17— ❑ ® 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 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. 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 Commonwealth of Massachusetts- Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every COtUIt MA 02635 9-3-19 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 CA 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 I Commonwealth of Massachusetts 9 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is CotUlt required for every MA 02635 9-3-19 page. City/Town 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: 1000 Gal. Tank D Box and pit. Number of current residents: 0 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2017-27,000 Gal Detail: 2018-67,000 Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA Date i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I Commonwealth of Massachusetts ip Title 5 Official Inspection Form Q Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Clamshell Cove Road V� Property Address Michael Burke Owner Owner's Name information is required for every Cotult MA 02635 9-3-19 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: NA 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 to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 page. City/Town 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: 1986 Permit #85- 1114/9-2019 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 40"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 4" PVC SCH -40. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 32" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" 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 18" 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 and outlet cover at 32" below grade w/inlet at 6". Inlet tee w/old outlet baffle. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 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 ❑ 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 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 ❑ other(explain): 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 I Commonwealth of Massachusetts I? Title 5 Official Inspection Form -10 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Clamshell Cove Road u- Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 page. City/Town 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.): *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 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"x 16"- 55" Below grade w/one line out Box is new 9-2019 w/cover at 6" II t5ins .doc•rev.7/26/201 p 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form rlo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 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.): * 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 ❑ leaching chambers number: f ❑ 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 � i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every COtUIt MA 02635 9-3-19 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.): Leaching is a 1000 Gal. precast pit. Pit and cover at 46" below grade. Pit dry w/no sign of over loading. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 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 to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 15 of 18 r c Commonwealth of Massachusetts I Title 5 Official Inspection Form = I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 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 j? APR A A 3 4 t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 page. City/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: 20'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Abutting area drops off 20'+. Bottom of pit at 10' below grade. Bottom of pit at 10' above lots in this area. I 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 f ip Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 82 Clamshell Cove Road Property Address Michael Burke Owner Owner's Name information is required for every Cotuit MA 02635 9-3-19 page. City/Town 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 .1 f(/a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 DATE: 7/23/99 PROPERTY ADDRESS:82_Clam Shell Cove Road Cotuit ,Mass . ------------------------ 02635 ------------------------ _60-7 q On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1-1000 gallon septic tank . 2 . 1-1000 gallon precast leaching pit . Based on my inspection, I certify the following conditions: 3 . This is a title Five Septic System. ( 78 Code ) 4 . The septic system is in proper working order at the present time . 5 . The septic tank needs to be pumped . 6 . Leaching pit is. 54" below grade . Cover should be raised . 7 . Waste water is 32" below the invrt pipe to the leaching pit . SIGNATURE: Name:_J. P . Macomber Jr_______ A , Company: Jose2h_P. Macomber_& Son , Inc . Address:— Box_6 6------------- A U(` Centerville Ma . 02632-0066 rowNe, Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • COMMONWEALTH OF M,A,SSACHUSETTS ` �► EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENvIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY CO. Secr@c ARGEO PAUL CELLUCCI DAVID g. STRU, Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION Proge Address: 82 Clam Shell Cove Road Name of own,"Bob McCutcheon Cotuit ,Mass . 02635 Address of owner: Data of 4upection: Name of Irupector:(Plaasa Prtrf0 Joseph P. Macomber Jr. I am a DEP approved system.Inspector pursuarrt to Section 15.340 of Tide 6 (310 CMR 15.000) companyNanw: Io seiph—Ir Macomber & Son, Inc. MaMNAddress: PnX 6 6 rpntervillp, Ma 02632-0066 Tej*phorx Number: r,()R_ 5—3 3 3 A CERTIFICATION STATEMENT I certify that 1 have personally Inspected the sewage disposal system at this address and that the Information reported below is true, accurate and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper function end maintenance of on•sit6 sa age disposal systems. The system: ZPasses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails �� In AM1114spector's Signature: l Data: 1 The System Inspector all submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system own@ Mall submit the report to the appropriate regional office of the Department ohfnv{ronmerual Protection. The original should Of sent to trrs system ownsr.and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COh1MENTS , revised 9/2/98 P2eeIof11 t� vr�t.d on aeryetea Prper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prop*MAddreas: 82 Clam Shell Cove Road Cotuit ,Mass . Owner: Bob McCutcheon Date Of trupection:7/2 3/9 9 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: /G. I have not found any information which Indicates that any of the failure conditions described in 310 CMR 1-5.303 exist. Any failure criteria not evaluated are Indicated below, COMMENTS: Rec : Septic tank be pumped and the cover on the 1 Par•hi ng nit hp rai Spy B. SYSTEM CONDITIONALLY PASSES: 'o'. 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. Indicate yes,no, or not determined(Y, N. or ND). Describe basis of determination In all Instances. If "not determined", explain why not. The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was Installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal,Is cracked,structurally unsound, show$ substantial infiltration or exfiltrauon, or tank failure Is Imminent. The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed In the istribution box s due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass nsp t on If(with approval of the Board of Health). broken pipe(s) are replaced obstruction Is removed distribution box Is levelled or replaced - The system required pumphig-mare then`four-dmes a yeardue to broken or obstructed pipe(s). The system wii1-jmrr^ Inspection If(with approval of the Board of Health): - - broken plpe(s) are'replaced obstruction Is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) p,.opertyAdr"s:82 Clam Sheel Cove. Road Cotuit Mass . Owner: Bob McCutcheon Date of Inspection: 7/2 3/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: D Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.lMLL.PROTECT THE PUBUC HEALTH.AND SAFETY AND THE ENWHONMENT: Cesspool or privy is within 50 feet-of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPUER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the press ce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance Ah (approximation not valid). 3) OTHER jhy revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART A ` CERTIFICATION (corrdnued) PropertY dres Ads:82 Clam Shell Cove Road Cotuit ,Mass . Owner: Bob McCutcheon Dste of u"Pe"don7/2 3/9 9 0. SYSTEM FAILS: You ust Indicate either 'Yes' or 'No' to each of the following: I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this - " determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No , , Backup o +swage irsto lec)Rty-or stem component duatto m overloaded orcbgged'SAS or cesspod. Discharge or pondlnt 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 istrlb uon box Bove outlet Invert due to an overloaded or clogged SAS or cesspool. Liquid depth In cress aal I less than 6' below Invert or available volume Is less than 112 day flow. 41 Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe($). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. Ll Any portion of a 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 16•within a Zone i of a public well. Any portion of a cesspool or privy Is within 60 feet of a private water supply well. Any portion of a cesspool or privy 1s less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the wall has been analyzed to be acceptable, attach copy of well water analysis for —colilorm bacteria, volatile otganiccompounds, ammonia nitrogen-and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either 'Yes' or 'No' to each of the following: The following criteria apply to Large systems In addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes Nq _ ,�{/ the system is within 300 lest of a surface drinking water supply the system•le-wltl4n 200 faet0l-a U lwleryio a wsfaoa�rinkw+g +a ter suOPly -- the system Is located Ina nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone 11 of a puDi.c water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Inlor.madon. r revised 9/2/98 Page 4of11 1 i j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 82 Clam Shell Cove Road Cotuit ,Mass . Owner: Bob McCutcheon Date of Inspection:7/2 3/9 9 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No/ Pumping information was provided by the owner, occupant, or Board of Health. 2 -None of the systemsompawnts ha►wbeen pua►ped►fovzatJeast twoaweelm and-the'aystem hasbaeoawceiaiag+wa"flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this / inspection. N As built plans have been obtained and examined. Note If they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,ikluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orr the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) ./ (15.302(3)(b)) Y _ _ The facility owner.(and.on—pants,if differapi i^+nrMat OQ.on tsap•Dpar-mainrana2c. ^f SubSurface Disposal Systems. I revised 9/2/98 Page 5ofII 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 82 .Clam Shell Cove Road Cotuit ,Mass . Owner: Bob McCutcr eon Date of Inspection:7/2 3/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: J10 g.p.d./bedro m. d Number of bedrooms(design : Number of bedrooms(actual):,) Total DESIGN flow�e, Number of current residents:,, Garbage grinder(yes or no):_ Laundry(separate system) es orQ_; If yes, sepacatelrtspection.required Laundry system inspected kfasor no) Seasonal use(yes or no):JQU Water meter readings,If avajlable(last two year's usage(gpd): � C � �� Sump Pump lye-or no): � Last date of occupancy: COMMERCIALANDUSTRIAL: Type of establishment: Design flow: J) god ( Based oP 15.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present:(yes or no)" Non-sanitary waste discharged to the Ti-Jo 5 system:(yes�o{no) i Water meter readings,If avails : - Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RE Lip ��sour�g gf I .Tation�! P&!Iy� � � System pumped as part of in action: (yes or no If yes, volume pumped: gallons Reason for pumping; TYPE OF YSTEM Septic tank/di-�i�ti we �eic/so I absorption system Single cesspool Overflow cesspool A Privy Shared system(yes or no) (if Yes, attach previous Inspection records;if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank W Copy of DEP Approval Other APPROXIMATE AGE of all components, date Installed{if known)-and source of4aformation: -----� Sewage odors detected when arriving at.the site: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'nON FORM PART C - SYSTEM INFORMATION (corrdnuod) Propo Add'.": 82 Clam Shell Cove Road Cotuit ,Mass . Owner: Bob McCutchegn Dsu of trapocdon: 7/2 3/9 9 BUILDING SEWER: (Locals on site plan) 7° 0•pth below grade:,y�,� Material of construction:_cast Iron Z40 PVC_other(expla.in) Distance hom prlvat• water supply well or suction Ilne71'IL__ Diameter /► _ Comments: (condition of Jolnts, venting, evidence of Iealcage Joints appPar tight Nrl leakage . ic: vent . (locate on sits plan) Depth below grad•: Material of construction:Zncret%W—met&WAFlberglassV ,Polyethy)sn#A,&other(explaln) If tank is (natal,Usst aJgo • Js.age.confv�mp'ed by CerJhcats of Compliance (Yes/No Dimensions: 7 i-lad 'Vl'0h 10,;k, / /4-j Sludge depth:_ Distance from top �ludge to bonom of outlet tee or bst(lo: ow Scum thickness: IL _ Distance from top of scum to top of outlet t•• or baffle: Distance from bonom of scum to bon o of outlet • or battle: How dimensions wars determined: Comments: (recommsndat)on for pumping, condition of Inlet and outlet tees or•bahfl•s, depth of liquid Ievel In ralatlon to outlet even. �vuctura . ce evidence of leakage, etc.) Pump tank PVPry 9-1 gpare Tn1eJ- A n„tlot TRA.P:A AM (locate on site plan) Depth below grader MaterlaJ of construedons�oncrstel9metAMFibsrglass/�A Polyethylen other(explain) Dimensions: Scum Wckn•as: 414 Oiatance from top of scum to top of outlet tee or baffl•:,Idd Distance from bonom of scu to bonom of outlet tee or baffle:, Date of last pumping: Comments: (rscommsndadon for pumping, condition of Intel and outlet teen or baffles. depth of liquid level In relation to outlet in,en. ,vvcrvrd int., evidence of leakage, etc.) Grease trap revised 9/2/98 Pagr7of11 I f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corrtirwad) Property Address:82 Clam Shell Cove Road Cotuit ,Mass . owner: Bob McCutcheori D" of Inspection:]/2 3/9 9 TIGHT OR HOLDING TANK-A&_Z(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade: Material of constructionsfl/A concreted•metal(j,LJFiberglassdtAPolyethylene(gother(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm�vjorking order: Ye&" No/� Date of previous pumping: 4 Comments: (condition of Inlet tee, condition of alarm and float switches, etc.) iQ t or holding tanks arp not pre-ens DISTRIBUTION BOX;�i (locate on site plan) Depth of liquid level above outlet Invert:_Aj�t— Comments: (note it level and distribution is equal, evideno-o of solids carryover, evidence of leakage Into or out of box, etc.) — — istribution box is not prPsant PUMP CHAMBER:AXW-- (locate on site plan) Pumps in working order:(Yes or No) Alerms In working order(Yes or No)le Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) temp chamber is not prPSPnt revised 9/2/98 Page 8orll 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) FTrW tyAdd—: 82 Clam Shell Cove Road Cotuit ,Mass . Owrw: Bob McCutcheon , Dav of Inspection:7/2 3/9 9 �r SOIL ABSORPTION SYSTEM(SAS): roximated by non-Intrusive methods! (locate on site plan. If possible: excevetio not required,location may be app If not located, explain: Type: leaching pits, number:- leaching chambers,number: leaching galleries,number, D leaching trenches,number,length: leaching fields, number, dimension overflow cesspool,number: I , Alternative system: �! Name of Technology: Comments: note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation..etc.) `,oam or rate on 1S nor CESSPOOLS: (locate on site plan) Number and configurAInvertv: Depth top of liquid toDepth of solids layer: Depth of scum layer: Dimensions of cesspMaterials of construcIndication of ground inflow (cesspool must be pumped as part of Inspection) e Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of,vegetation, etc, ass PRIVY:�� (locate on site plan) Dimensions: /U Materials of constructi n, Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, revel of ponding, condition of vegetation;etc.) riv is Page 9 of 11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART C ' SYSTEM INFORMATION (coadrxrod) h Prog6MAd&"-&: 82 Clam., Shell Cove Road Cotuit ,Mass . Owr.*(: Bob McCutchpon Do, °}UuPoc'«"7/23/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ds$to at Fast two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) WIN �I revised 9/2/98 Pap 10of 11 i y •r'nr�.—nrsr r� rnr-nn•nnw�^m+++n.�+.nn�.•�w•vn�re�nr�rsrrwti s►����yn .. . I TOWN OFBARNSTABLE IlUARll OF HEALTH �_•Tr,--••-:.'-*,"n_SUJlSU1tFACF 9FN�AQF I)I f'USAL� Y�9TF.M INS 9I', FCTION FORM - PART D^- CEItTf FICAT1()N r ' - -TTPt OR PRINT CIZ ARLY- PROPERTY INSPECTED STREET ADDRESS 82 Clam Shell Cove Road Cotuit ,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Bob McCutcheon PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber- Jr. COMPANY NAME Joseph P. Macomber & Son, Inc. COMPANY ADDRESS Box 66, Centerville, Ma. 0263.2-0066 Street Town or City Stat. tIP COMPANY TELEPHONE (508 )775 -3338 FAX ( 508 )790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa"l system at this address and that the information reported is true , accurate , and complete as of the time of -inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Chec one : Sys teui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or, the environment as defined in 310 CMR 15 , 303 . Any failur-e criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAIL v* The inspection which I have conattcted has found that the system fails to protect the }-itIblic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspect on form . Inspector Signature Date Al One copy of this e r t i f i c a t i o n must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF IMAL7'll. • If the inspection FAILED, th'e owner or•#'oporator shall upgrade he aye tem within one year of the date of the inapection , unless allowed Ortrequired otherwise as provided in 3.10 CMR 16 , 306 . partd . doc I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 4 SYSTEM INFORMATION(continued) P►openyAd&—: 82 Clam Shell Cove Road Cotuit ,Mass . owner: Bob McCutcheon Date of kupecdon:7/2 3/9 9 NRCS Report name Soli Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells �t r Estimated Depth to Groundwater I`�t-Feet Please Indicate all the methods used to determine High Groundwater Elevation: 2Obtalned from Design Plans on record Observed.Site(Abutting property observation hole, basement sump etc.) Determined from local conditions _Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Cahrety & Miller Model 12/16/94 revised 9/2/98 Page II of II V EJ oq ,C� a_��4- THE COMMONWEALTH OF MASSACHUSETTS V \ BOARD HEALTH .:.............oF........- �LX .............. ApplirFation for Disposal Works Tonstrnrtion Vamif Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal System at: . `- Zo......C./. .. lt //...- yr '� af �..7`-... o :� � Location-Address or Lot No. -----•-•----- ....-.--.•-- 6s� Cc3 lJn Ad"ice' ie Ads a.._...... Pal Installer Address Type of Building Size Lot---.-.._s._...3._J_aSq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons......................... Showers W YP g ---------------------------- P --- ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow...........................___.gallons per person $er day. Total daily flow..............3.3-L0...............gallons. WSeptic Tank—Liquid*capacityd_ePP.gallons Length 8__ ...... Width__f!e .4'.__ Diameter................ Depth..12....- ... x Disposal Trench—No...............•..... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No....../------------- Diameter.A...-.6_.... Depth below inlet.....(a__.......... Total leaching area..46J71sq. ft. z Other Distribution box (V/5" Dosing to ) �J S'G�4t✓1���` Date 8 66 a Percolation Test Results Performed by....................................................................... -'-----1_......-- Test Pit No. 1....X-......minutes per inch Depth of Test Pit---/Y.Vn....... Depth to ground water---------•---. f14 Test Pit No. 2-----?�-.....minutes per inch Depth of Test Pit__/_.Y._ef....... Depth to ground water........................ a -•---••--•-------------•-----•-----•-----------•---•----......---------......... .... O Description of Soil..---�I<% lc�...�).6Y ------...w4tA� _�j�w------------ W U ••••-•-•------------------------------------------------•-----••------••-•-•---•-----.............----•--•-•••-•-•----•-----------------•-••-•---------................................................ W -------------------------------------------------------------------------------------•-•-•--------------------•-----------------------•---------------•--•--------...-•----------------....-•--•-...... U Nature of Repairs or Alterations—Answer when applicable-------------------------------................................................................. -----------------------------------------------------------•-•---•----------...._...--•---------...------....•----------------------•••---•••---------•----•--•-----•--•-•--••-••-•-•-•-------------••- Agreement: The undersigned agrees to install the. aforedescribed Individual Sewage Disposal m S ste in accordance with � g g P Y the provisions of iI,L% of the State Sanitary C e e u ersigned further agrees not to place the system in operatibo until a Certificat of Complia ce has en ' s ed b� a oard of health. i ned..... D t Application Approved BY......................... •-•--•--. .... ✓ ................... .-•-----1 - C� Date Application Disapproved for the followin easons-----------------------------------------------•------........................................................- -•..........................•----•----------•------••----------------•--•------------•---...------------.----•----•-•••--••---•--•----•---------•--••-••-••-----•------...---•••----••----•----•--••--•- Date PermitNo........ ..................................... Issued....................................................... Date .... , No---- "-)+1 4" Fps ._....._.... THE COMMONWEALTH OF MASSACHUSETTS b- 74-- BOARD HEALTH f?...................OF...... ............ ��', /�, .................... Appliration for Uhipaii al 19ork.5 Tatuitrur#ion Prrutit Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal System at: - �?`� Z O aq`� 5 �r /r.- - •vvs ....................................... _._v` 7�" Location-C Address or Lot No. - Owner Address W Installer Address Q Type of Building Size Lot.'Ky....2.rd9q. feet U Dwelling—No. of Bedrooms...............:........_..........Expansion Attic ( ) Garbage Grinder ( ) P.,., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ............................ . W Design Flow........................s_ .........gallons per person peryday. Total daily yflow............_ 3_C:2...............gallons. WSeptic Tank—Liquid capacity 144O.gallons ,Length.8.!....... Width-.ter._.� _--... Diameter................ Depth..'�.:`i..._. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit NO....../------------ Diameter..lb...__ ..___ Depth below inlet....a............ Total leaching area..eaj:1sq. ft. Z Other Distribution box (V/)� Dosing tak ) ~' Percolation Test Results Performed by__.�...:__-.L .0 14)T✓�......................... Date..... _ . _g a Test Pit No. I....Z.......minutes per inch Depth of Test Pit... - r_-....... Depth to ground water....................... (Z, Test Pit No. 2-----n .....minutes per inch Depth of Test Pit..l-Y_.y....... Depth to ground water......................... ---•-•---------------------••--•-•'---.....----.........---------------..............j..................................................................... D Description of Soil....... w ......... A V ......... DU• �� ................. .r-••------------•----•-•----------.............................................. 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 TITIS 5 of the State Sanitary Code—The u rsigned further agrees not to place the system in operation until a Certificate if jCompliance has en ed b b and of health. Date Application Approved By.................... ---•-----------..._---•-- Application Disapproved for the f ollo i g reasons-----------------------------= .......................................................... _ ...............................•--•'•----•--•--•....-•------------------.....-----------'.................-----•--------•-------- .................................................... Date Permit No..........?D50 :...I Issued ............................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrfif iratr of Tootplitturr THIS fS TQ CERTIFY, That the.Ind,* idual Sewa e pi�posal System constructed ( ) or Repaired ( ) by----------------.....`;.. '�r`�-_t`��=='�'.......................... .....-�............ ....................'.. -•••----•--••------------•-.•...•.....-•................•-••-••-----••-. r-- �' Installer at........................ - .. ........................................................................................... has been installed in accordance with the provisions of TITIE 5-of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........................................... ' Jated....................!_______-_I.......,......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FU T ON S TISFACTORY. DATE.................. = Z- ................ Inspector.................'•••--...........-•----•-------------..._..._....._-••-••......••-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF..................................................................................... Bioposal Works Tono#rudiott rrm Permission is hereby granted.......FA-f:: J' i- ---....{°'.;ii..,�C�.�. ......_.. ... to Construct ( ) or Repair ( ) an Individualv�Tage 17i �fo �1�yste�n at No.. 4 3{� K�(Si�(•iEtf -OOet /� ;' V as shown on the application for Disposal Works Construction Permit La. ..... Dated.......................................... ord .-4e---- ---•------------------•----•--•-----••_ DATE //. ......s ........ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS '� LOCATION SEWAGE PERMIT NO. VILLAGE (77'a I N S T A LLER'S A M E A ADDRESS elllexl t S U I L D E/R� OR OWN ER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 3� �, i.a a �o TP-o.0 i 1 k S YS TEM PROFILE NOT TO SCALE TOP FON. FINISH GRADE OVER EL . ` ' a °� , FINISH GRADE OVER PIS T. BOX _ FINISH GRADE OVER ° SEPTIC TANK o f LEACHING PIT o VARIES D: a. ° ...t 1 1 . . .•. 3" OF 1/B" 1/2" PRECAST CONC. OR SHED PEAS TONE BRICK 6 MORTAR ° OUTLET PIPE LEVEL 1 TO 12" BEL OW GRADE FOR 2 FT. MIN. ��o.O.�..p;A°;'0:t0:b.�0. .0:oao°.'°o._rO. o•Ll 'a ~ .. .T..T. . pC e ° • •o .e.�,G,•• ,, ::.•. •'s.. ..: o o G . f e o.o. .a: �, "e p .jQ 7'�o'o. D --- C. I. OR PVC TEES o D IQ • BSMT. FLR. `'�' �— ► _ czF �- _ . ._.? 1 GALLON I..e. EL DIS TRIBU TION BOX I e ° s ° INSTALL ON LEVEL BASE 3/4 " TO 1-1/2" • ° o --__ PRECAST CONCRETE PRECAST — ! 0 REINFORCED � WASHED H 0 4 D 0 0 f � 1 I a CRUSHED CONCRETE — ------ e o 0 1 00 o e o .o. o o e o Q 'o D o' • . _ :6 a e:o a. STONE , 0:,o o. p 0 0 o ° O.p o o e ,o O o ° 0:O O :p O o o ° I Q • H— �/0 REINF. b, e� I SEPTIC TANK n d INSTALL ON LEVEL BASE NOTE.' EXCA VA TE TO ELEV. - OR LOWER TO REMOVE AIMPERVIOUS I• ° ° °—° —�—A r-� ALL `— - - MA TERIAL BENEA TH THE L EA CHING AREA REPL A CE EXCA VA TED MA TERIA L WI TH CL EAN, CL A Y FREE SAND EFFECTI VE DIAMETER _ S L v T GENERAL NOTES LEACHING PIT I . ALL ELEVATIONS SHOWN ARE BASED ON INS TALL ON LEVEL BASE �6, ��� 2. A L L PIPES IN THE S YS TEM MUS T BE CAS T IRON OR SCHEDULE 40 PVC. OBSER VA TION PIT 3. THE BOARD OF HEAL TH MUST BE NOTIFIED WHEN CONSTRUCTION IS COMPLETE PRIOR TO BA CKFIL L ING PERCOL A TION PATE' o . 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED MIN. /IN. \ 100 \ 1000 SALI.aV -' BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS WI TNESSED B Y.•t SURVEYING CO., INC. R. �.! <L 5. MATERIALS AND INSTALLATION SHALL BE IN A ,.- � \ COMPLIANCE WI TH THE STA TE SA NI TARY . H BRO. OF HEALTH DESIGN DA TA CODE — TITLE V — AND LOCAL APPLICABLE DA TE.' A//:7, RUL ES AND REGUL A TIONS p/� � P/7- �, 7 �. ,. NUMBER OF BEDROOMS 6 IS RTH NO TA�O BES FPOM USED FOR SO�AAPLANS ANDPURPOSES GA RBA GE DI SPOSA L ti • ( �2P) 9 ToAS4j DAILY FLOW FLOOD HAZARD ZONE . B. WA TER SUPPL Y SEPTIC TANK REO O. m SEPTIC TANK PROVIDED l a'D y LEACHING REOUIRED Q_ 4-0 PMcASr CQVQlt7Ft- s sgNz Q SIDEWALL AREA S. F. ;9i S. F. X Z • G/S. F.'= 41?7 GPO `t b�?� 24, '��CJt � BOTTOM AREA = 7 S. F. .q 2 6 - .. �_-- _�-___ _ � LEGEND NO y✓��"E' S. F. X G/S. F. = u. � GPD �/7 LEA S. PROVIDED = GPD OW PROPOSED EL EVA TION E�• 30,7 EL. �Q. d EXISTING CON TOUR SINGLE FAMILY RESIDENCE G ,• OBSERVA TION PIT 0 DISTRIBUTION BOX `\ ��` ;`"�= PROPOSED SEWA GE DISPOSAL S YS TEM Col a � ROM PREPARED FOR o o SEPTIC TANK CO YSBROOK INC. tRpl RESERVE LOT 20 CL A MSHEL L COVE ROAD � AIll BA RNS TA BL E — CO TUI T — MASS. `f`' PIPE INVERT ELEVA TION A.N; K1 DA TE. li - �f _ CAPE 6 ISLANDS SURVEYING, INC. PLOT PLAN �o r 4 , SCALE A S NO TED SCALE: 1 ' _ �7 0" .� ,�, P. 0. BOX 334 MAP SEC PCL LOT HSE PL A IVNO. "n :: TEA T I CKE T, MASS.